Provider Demographics
NPI:1053399279
Name:LYDELL-JONES, DIANN RENEE (CRNA, FNP-C)
Entity type:Individual
Prefix:
First Name:DIANN
Middle Name:RENEE
Last Name:LYDELL-JONES
Suffix:
Gender:F
Credentials:CRNA, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7150 CLEARVISTA DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1695
Practice Address - Country:US
Practice Address - Phone:317-621-5890
Practice Address - Fax:317-621-7884
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006851A363L00000X
IN28156532A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200474980Medicaid
INM400044850Medicare PIN
INM00070977Medicare PIN
M400025860Medicare PIN