Provider Demographics
NPI:1972028504
Name:FAHMY, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:FAHMY
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 1:58 WILDWOOD TER
Mailing Address - Street 2:
Mailing Address - City:WATCHUNG
Mailing Address - State:NJ
Mailing Address - Zip Code:07069-5815
Mailing Address - Country:US
Mailing Address - Phone:1908-917-8904
Mailing Address - Fax:908-822-2234
Practice Address - Street 1:58 WILDWOOD TER
Practice Address - Street 2:
Practice Address - City:WATCHUNG
Practice Address - State:NJ
Practice Address - Zip Code:07069-5815
Practice Address - Country:US
Practice Address - Phone:908-917-8904
Practice Address - Fax:908-822-2234
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00664600363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health