Provider Demographics
NPI:1013761113
Name:MOULTRIE, DIANNE ELIZABETH
Entity Type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:ELIZABETH
Last Name:MOULTRIE
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 1:274 NORTH GOODMAN STREET
Mailing Address - Street 2:BUILDING B
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607
Mailing Address - Country:US
Mailing Address - Phone:585-514-0651
Mailing Address - Fax:
Practice Address - Street 1:274 NORTH GOODMAN STREET
Practice Address - Street 2:BUILDING B
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607
Practice Address - Country:US
Practice Address - Phone:585-514-0651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist