Provider Demographics
NPI:1285628149
Name:LOOMIS, DIANNE M (FNP)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:M
Last Name:LOOMIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 NIAGARA ST
Mailing Address - Street 2:UBMD AT LAKESHORE
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14201-1886
Mailing Address - Country:US
Mailing Address - Phone:716-856-2587
Mailing Address - Fax:
Practice Address - Street 1:430 NIAGARA ST
Practice Address - Street 2:UBMD AT LAKESHORE
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201-1886
Practice Address - Country:US
Practice Address - Phone:716-856-2587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331078207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00384643Medicaid
NYBB0984Medicare ID - Type Unspecified
NY00384643Medicaid