Provider Demographics
NPI:1285045757
Name:DETTMORE, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:DETTMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 MONTROSS AVE
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-1147
Mailing Address - Country:US
Mailing Address - Phone:551-206-9812
Mailing Address - Fax:
Practice Address - Street 1:1340 HAMBURG TPKE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-4003
Practice Address - Country:US
Practice Address - Phone:973-633-1996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-18
Last Update Date:2014-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00456900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health