Provider Demographics
NPI:1346910551
Name:IVEZAJ, DIANA D (NP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:D
Last Name:IVEZAJ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PORT WASHINGTON BLVD STE G05
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-1347
Mailing Address - Country:US
Mailing Address - Phone:516-365-4888
Mailing Address - Fax:516-365-4820
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1347
Practice Address - Country:US
Practice Address - Phone:516-365-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-18
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY348243363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily