Provider Demographics
NPI:1417197633
Name:MAZZO, DIANNE LYNNE (ARNP)
Entity Type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:LYNNE
Last Name:MAZZO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:MS
Other - First Name:DIANNE
Other - Middle Name:LYNNE
Other - Last Name:SECRETO-MAZZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:123 FRONTIER DR
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-4433
Mailing Address - Country:US
Mailing Address - Phone:386-264-1130
Mailing Address - Fax:
Practice Address - Street 1:301 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5167
Practice Address - Country:US
Practice Address - Phone:386-264-1130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-27
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9284326363LF0000X
CA95025681363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily