Provider Demographics
NPI:1003396839
Name:PANCHAK, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:PANCHAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 CENTER DR
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-1078
Mailing Address - Country:US
Mailing Address - Phone:631-774-7767
Mailing Address - Fax:
Practice Address - Street 1:18 CENTER DR
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-1078
Practice Address - Country:US
Practice Address - Phone:631-774-7767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY536926360174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist