Provider Demographics
NPI:1811026370
Name:GOLDBERG, DIANE (RN)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 PAMMER RD
Mailing Address - Street 2:PO BOX 89
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12791
Mailing Address - Country:US
Mailing Address - Phone:845-482-5135
Mailing Address - Fax:
Practice Address - Street 1:4504 STATE ROUTE 55
Practice Address - Street 2:
Practice Address - City:SWAN LAKE
Practice Address - State:NY
Practice Address - Zip Code:12783
Practice Address - Country:US
Practice Address - Phone:845-292-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4969341163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse