Provider Demographics
NPI:1285824177
Name:COLAVITO, DIANE (RN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:COLAVITO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:COLAVITO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8 WILNER RD
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-3002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8 WILNER RD
Practice Address - Street 2:
Practice Address - City:SOMERS
Practice Address - State:NY
Practice Address - Zip Code:10589-3002
Practice Address - Country:US
Practice Address - Phone:914-248-8931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY375321-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01623770Medicaid