1598856601 NPI number — MRS. DIANE ELIZABETH PRIMAVERA FNP

Table of content: MRS. DIANE ELIZABETH PRIMAVERA FNP (NPI 1598856601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598856601 NPI number — MRS. DIANE ELIZABETH PRIMAVERA FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRIMAVERA
Provider First Name:
DIANE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598856601
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 421
Provider Second Line Business Mailing Address:
CRMC PHYSICIAN SERVICES
Provider Business Mailing Address City Name:
HARRIS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12742-0421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-794-9864
Provider Business Mailing Address Fax Number:
845-794-9868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
60 JEFFERSON ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12701-1122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-794-7897
Provider Business Practice Location Address Fax Number:
845-794-1756
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  F333105 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: F333105 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LX0001X , with the licence number: F333105 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02391293 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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