Provider Demographics
NPI:1083773386
Name:CAVANAUGH, DIANNE EDWINA (NP)
Entity Type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:EDWINA
Last Name:CAVANAUGH
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 1:2510 30TH AVE
Mailing Address - Street 2:MOUNT SINAI HOSPITAL QUEENS
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-2448
Mailing Address - Country:US
Mailing Address - Phone:718-932-1000
Mailing Address - Fax:
Practice Address - Street 1:2510 30TH AVE
Practice Address - Street 2:MOUNT SINAI HOSPITAL QUEENS
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-2448
Practice Address - Country:US
Practice Address - Phone:718-932-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335551363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400000114Medicare PIN