Provider Demographics
NPI:1417686809
Name:DIANA, JENNA MARIE (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:DIANA
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:MARIE
Other - Last Name:LAUKAITIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:61 HUNTINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3735
Mailing Address - Country:US
Mailing Address - Phone:516-987-2108
Mailing Address - Fax:
Practice Address - Street 1:26901 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1433
Practice Address - Country:US
Practice Address - Phone:718-470-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY383207363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics