Provider Demographics
NPI:1700397486
Name:DIEMIDIO, MARISSA LYNN (LPN)
Entity Type:Individual
Prefix:MS
First Name:MARISSA
Middle Name:LYNN
Last Name:DIEMIDIO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1574 LOUIS KOSSUTH AVE
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-1512
Mailing Address - Country:US
Mailing Address - Phone:631-241-7594
Mailing Address - Fax:
Practice Address - Street 1:1574 LOUIS KOSSUTH AVE
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-1512
Practice Address - Country:US
Practice Address - Phone:631-241-7594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-20
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330041164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty