Provider Demographics
NPI:1134328578
Name:DIFAZIO, DIANE ALEXANDER (MSN, CPNP)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:ALEXANDER
Last Name:DIFAZIO
Suffix:
Gender:F
Credentials:MSN, CPNP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MICHELLE
Other - Last Name:ALEXANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3 COOPER PLZ
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1438
Mailing Address - Country:US
Mailing Address - Phone:856-342-2000
Mailing Address - Fax:
Practice Address - Street 1:3 COOPER PLZ
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1438
Practice Address - Country:US
Practice Address - Phone:856-342-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP004652N363LP0200X
NJNN72874363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
077356Medicare PIN