Provider Demographics
NPI:1679238992
Name:FERNANDEZ TELLEZ, DIANA CAROLINA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:CAROLINA
Last Name:FERNANDEZ TELLEZ
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 1:198 COURT HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:00101
Mailing Address - Country:US
Mailing Address - Phone:631-624-8858
Mailing Address - Fax:
Practice Address - Street 1:198 COURT HOUSE RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:00101
Practice Address - Country:US
Practice Address - Phone:631-624-8858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY824287163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse