Provider Demographics
NPI:1740403641
Name:MANUS-BIANCULLI, DIANE (NP,C)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:
Last Name:MANUS-BIANCULLI
Suffix:
Gender:F
Credentials:NP,C
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:BIANCULLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP,C
Mailing Address - Street 1:1600 BRECKNOCK RD
Mailing Address - Street 2:
Mailing Address - City:GREENPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11944-3100
Mailing Address - Country:US
Mailing Address - Phone:631-477-4216
Mailing Address - Fax:631-477-4065
Practice Address - Street 1:1600 BRECKNOCK RD
Practice Address - Street 2:
Practice Address - City:GREENPORT
Practice Address - State:NY
Practice Address - Zip Code:11944-3100
Practice Address - Country:US
Practice Address - Phone:631-477-4216
Practice Address - Fax:631-477-4065
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302342363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS68793Medicare UPIN