Provider Demographics
NPI:1487227971
Name:PRATT, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:PRATT
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 1:744 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-3802
Mailing Address - Country:US
Mailing Address - Phone:201-920-9031
Mailing Address - Fax:
Practice Address - Street 1:744 BROAD ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-3802
Practice Address - Country:US
Practice Address - Phone:201-920-9031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0183385Medicaid
NJ0183393Medicaid