Provider Demographics
NPI:1669502662
Name:MALLETTE, DYAN M (FNP)
Entity Type:Individual
Prefix:
First Name:DYAN
Middle Name:M
Last Name:MALLETTE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:35 WRIGHT CAMP DR
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-4223
Mailing Address - Country:US
Mailing Address - Phone:315-393-8955
Mailing Address - Fax:
Practice Address - Street 1:9 MINER ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1208
Practice Address - Country:US
Practice Address - Phone:315-386-8821
Practice Address - Fax:315-386-4723
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333467363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00583697Medicaid