Provider Demographics
NPI:1497469209
Name:SOUTHERLAND, NYDIA DIANE
Entity Type:Individual
Prefix:
First Name:NYDIA
Middle Name:DIANE
Last Name:SOUTHERLAND
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 1:3523 CLARENDON RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-5101
Mailing Address - Country:US
Mailing Address - Phone:347-873-9864
Mailing Address - Fax:
Practice Address - Street 1:3523 CLARENDON RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-5101
Practice Address - Country:US
Practice Address - Phone:347-873-9864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY843246174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist