Provider Demographics
NPI:1467781468
Name:DIEGO, CHARLENE
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:DIEGO
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 1:123 BEACH 60TH ST
Mailing Address - Street 2:
Mailing Address - City:ARVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11692-1849
Mailing Address - Country:US
Mailing Address - Phone:718-318-0447
Mailing Address - Fax:
Practice Address - Street 1:123 BEACH 60TH ST
Practice Address - Street 2:
Practice Address - City:ARVERNE
Practice Address - State:NY
Practice Address - Zip Code:11692-1849
Practice Address - Country:US
Practice Address - Phone:718-318-0447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY286757164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse