Provider Demographics
NPI:1609068758
Name:FLANAGAN, DIANE BARBARA (RN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:BARBARA
Last Name:FLANAGAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PAYNES LANE
Mailing Address - Street 2:
Mailing Address - City:EAST QUOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11942-4110
Mailing Address - Country:US
Mailing Address - Phone:631-653-8121
Mailing Address - Fax:
Practice Address - Street 1:1095 CUSTER AVENUE
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971
Practice Address - Country:US
Practice Address - Phone:631-765-0031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2239821163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00917542Medicaid