Provider Demographics
NPI:1629332036
Name:FIELDS, DIANE ALIS
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:ALIS
Last Name:FIELDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14012 RT 31 W
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:NY
Mailing Address - Zip Code:14411-9372
Mailing Address - Country:US
Mailing Address - Phone:585-589-2778
Mailing Address - Fax:585-589-3169
Practice Address - Street 1:14012 RT 31 W
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:NY
Practice Address - Zip Code:14411-9372
Practice Address - Country:US
Practice Address - Phone:585-589-2778
Practice Address - Fax:585-589-3169
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03002119Medicaid