Provider Demographics
NPI:1790985968
Name:DIETZEN, DANIELLE NICOLE (CPNP)
Entity Type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:NICOLE
Last Name:DIETZEN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 FORT WASHINGTON AVE
Mailing Address - Street 2:IP-7
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032
Mailing Address - Country:US
Mailing Address - Phone:212-305-2642
Mailing Address - Fax:212-342-5220
Practice Address - Street 1:161 FORT WASHINGTON AVE
Practice Address - Street 2:IP-7
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-305-2642
Practice Address - Fax:212-342-5220
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF-381919363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics