Provider Demographics
NPI:1053673681
Name:RIVERA SHELTON, DIANE (MS SPECIAL ED)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:RIVERA SHELTON
Suffix:
Gender:F
Credentials:MS SPECIAL ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 QUAKER ST
Mailing Address - Street 2:
Mailing Address - City:WALLKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12589-5900
Mailing Address - Country:US
Mailing Address - Phone:646-591-3048
Mailing Address - Fax:
Practice Address - Street 1:329 QUAKER ST
Practice Address - Street 2:
Practice Address - City:WALLKILL
Practice Address - State:NY
Practice Address - Zip Code:12589-5900
Practice Address - Country:US
Practice Address - Phone:646-591-3048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY469681041390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY174400000XOtherTAXONOMY