Provider Demographics
NPI:1578796884
Name:MASTRIANO, DIANE (M TH)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:MASTRIANO
Suffix:
Gender:F
Credentials:M TH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9102 215TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1226
Mailing Address - Country:US
Mailing Address - Phone:718-776-6602
Mailing Address - Fax:734-448-6795
Practice Address - Street 1:9102 215TH ST
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-1226
Practice Address - Country:US
Practice Address - Phone:718-776-6602
Practice Address - Fax:734-448-6795
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0004945-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist