Provider Demographics
NPI:1053790030
Name:DURRELL, DIANE L (RN)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:L
Last Name:DURRELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:DIANE
Other - Middle Name:L
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04937-0358
Mailing Address - Country:US
Mailing Address - Phone:207-453-4708
Mailing Address - Fax:207-453-6250
Practice Address - Street 1:1604 BENTON AVE
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:ME
Practice Address - Zip Code:04901-3327
Practice Address - Country:US
Practice Address - Phone:207-453-4708
Practice Address - Fax:207-453-6250
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-25
Last Update Date:2015-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN24397163W00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No163W00000XNursing Service ProvidersRegistered Nurse