Provider Demographics
NPI:1598856601
Name:PRIMAVERA, DIANE ELIZABETH (FNP)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:ELIZABETH
Last Name:PRIMAVERA
Suffix:
Gender:F
Credentials:FNP
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Other - Credentials:
Mailing Address - Street 1:PO BOX 421
Mailing Address - Street 2:CRMC PHYSICIAN SERVICES
Mailing Address - City:HARRIS
Mailing Address - State:NY
Mailing Address - Zip Code:12742-0421
Mailing Address - Country:US
Mailing Address - Phone:845-794-9864
Mailing Address - Fax:845-794-9868
Practice Address - Street 1:60 JEFFERSON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-1122
Practice Address - Country:US
Practice Address - Phone:845-794-7897
Practice Address - Fax:845-794-1756
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2010-03-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NYF333105207Q00000X, 363L00000X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02391293Medicaid
NY0E0051Medicare PIN
P20927Medicare UPIN