Provider Demographics
NPI:1750493201
Name:WIZEMAN, DIANE M
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:WIZEMAN
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 1:253 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830-3301
Mailing Address - Country:US
Mailing Address - Phone:607-936-0209
Mailing Address - Fax:
Practice Address - Street 1:76 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-0810
Practice Address - Country:US
Practice Address - Phone:607-664-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22 259 677163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice