Provider Demographics
NPI:1386832558
Name:NIELSEN, DIANA FRANCIS (PTA)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:FRANCIS
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 LEEDS BLVD
Mailing Address - Street 2:
Mailing Address - City:FARMINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11738-1147
Mailing Address - Country:US
Mailing Address - Phone:631-698-4032
Mailing Address - Fax:
Practice Address - Street 1:240 MEETING HOUSE LN
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5009
Practice Address - Country:US
Practice Address - Phone:631-726-8520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant