Provider Demographics
NPI:1619143294
Name:DIANE M KOTSAFTIS
Entity Type:Organization
Organization Name:DIANE M KOTSAFTIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOTSAFTIS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:978-486-9898
Mailing Address - Street 1:531 KING ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LITTLETON
Mailing Address - State:MA
Mailing Address - Zip Code:01460-1279
Mailing Address - Country:US
Mailing Address - Phone:978-486-9898
Mailing Address - Fax:978-486-9770
Practice Address - Street 1:531 KING ST
Practice Address - Street 2:SUITE 3
Practice Address - City:LITTLETON
Practice Address - State:MA
Practice Address - Zip Code:01460-1279
Practice Address - Country:US
Practice Address - Phone:978-486-9898
Practice Address - Fax:978-486-9770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA86736363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANPG002OtherBLUE CROSS BLUE SHIELD