Provider Demographics
NPI:1417498346
Name:YOUNG, DIANA S
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:S
Last Name:YOUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 AVENUE P
Mailing Address - Street 2:
Mailing Address - City:MATAMORAS
Mailing Address - State:PA
Mailing Address - Zip Code:18336-1427
Mailing Address - Country:US
Mailing Address - Phone:845-282-4117
Mailing Address - Fax:
Practice Address - Street 1:101 AVENUE P
Practice Address - Street 2:
Practice Address - City:MATAMORAS
Practice Address - State:PA
Practice Address - Zip Code:18336-1427
Practice Address - Country:US
Practice Address - Phone:845-282-4117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-11
Last Update Date:2017-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY326318-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse