Provider Demographics
NPI:1407333560
Name:MOLTER, DIANE M (RN)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:M
Last Name:MOLTER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-4407
Mailing Address - Country:US
Mailing Address - Phone:631-218-4711
Mailing Address - Fax:
Practice Address - Street 1:795 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-2336
Practice Address - Country:US
Practice Address - Phone:631-434-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-22
Last Update Date:2018-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5185771163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5185771OtherRN LICENSE NUMBER