Provider Demographics
NPI:1003810755
Name:MCCLURE, DIANE E (CPNP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:E
Last Name:MCCLURE
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:PO BOX 32730
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06150-2730
Mailing Address - Country:US
Mailing Address - Phone:973-773-0100
Mailing Address - Fax:973-773-2101
Practice Address - Street 1:703 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2621
Practice Address - Country:US
Practice Address - Phone:973-754-2555
Practice Address - Fax:973-754-2567
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NC07080600363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0053546Medicaid