Provider Demographics
NPI:1972836096
Name:GONZALEZ, DIANE LYNN (PHARM D)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNN
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 S OYSTER BAY RD
Mailing Address - Street 2:
Mailing Address - City:BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11714-1038
Mailing Address - Country:US
Mailing Address - Phone:516-433-4029
Mailing Address - Fax:516-433-4087
Practice Address - Street 1:777 S OYSTER BAY RD
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-1038
Practice Address - Country:US
Practice Address - Phone:516-433-4029
Practice Address - Fax:516-433-4087
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053245183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist