Provider Demographics
NPI:1609126937
Name:SIMONETTI, DIANNE CAROL (LMT)
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:CAROL
Last Name:SIMONETTI
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CAYLA LANE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STA.
Mailing Address - State:NY
Mailing Address - Zip Code:11776-0000
Mailing Address - Country:US
Mailing Address - Phone:631-828-5337
Mailing Address - Fax:
Practice Address - Street 1:8 CAYLA LANE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STA.
Practice Address - State:NY
Practice Address - Zip Code:11776-0000
Practice Address - Country:US
Practice Address - Phone:631-828-5337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013171-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist