Provider Demographics
NPI:1407089477
Name:FERNICOLA, DIANE MARIE (APN)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:FERNICOLA
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MARYANN PL
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-4597
Mailing Address - Country:US
Mailing Address - Phone:732-232-0158
Mailing Address - Fax:
Practice Address - Street 1:1300 HIGHWAY 35
Practice Address - Street 2:PLAZA II, SUITE 102
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-3537
Practice Address - Country:US
Practice Address - Phone:732-663-1123
Practice Address - Fax:732-663-1179
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00244000363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care