Provider Demographics
NPI:1982180303
Name:BUSH, DIANE MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:BUSH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MARIE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:404 STATE ROUTE 37
Mailing Address - Street 2:
Mailing Address - City:HOGANSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13655
Mailing Address - Country:US
Mailing Address - Phone:518-358-3141
Mailing Address - Fax:518-358-9175
Practice Address - Street 1:404 STATE ROUTE 37
Practice Address - Street 2:
Practice Address - City:HOGANSBURG
Practice Address - State:NY
Practice Address - Zip Code:13655
Practice Address - Country:US
Practice Address - Phone:518-358-3141
Practice Address - Fax:518-358-9175
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY140456-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse