Provider Demographics
NPI:1114126166
Name:THOMAS, DIANE MARIE (RN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1353 STATE RTE 167
Mailing Address - Street 2:
Mailing Address - City:JORDANVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13361
Mailing Address - Country:US
Mailing Address - Phone:315-858-0835
Mailing Address - Fax:
Practice Address - Street 1:1353 STATE RTE 167
Practice Address - Street 2:
Practice Address - City:JORDANVILLE
Practice Address - State:NY
Practice Address - Zip Code:13361
Practice Address - Country:US
Practice Address - Phone:315-858-0835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3481471163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02871709Medicaid