Provider Demographics
NPI:1073631610
Name:DIAZ, MELANIE MARIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:MARIE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27005 76TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1433
Mailing Address - Country:US
Mailing Address - Phone:718-470-7852
Mailing Address - Fax:718-470-4304
Practice Address - Street 1:27005 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1433
Practice Address - Country:US
Practice Address - Phone:718-470-7852
Practice Address - Fax:718-470-4304
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY457603163W00000X
NYF304150363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse