Provider Demographics
NPI:1710436050
Name:JEANITE, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:JEANITE
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 1:76 S BERGEN PL
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-3505
Mailing Address - Country:US
Mailing Address - Phone:718-216-8924
Mailing Address - Fax:
Practice Address - Street 1:76 S BERGEN PL
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3505
Practice Address - Country:US
Practice Address - Phone:718-216-8924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY326843164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse