Provider Demographics
NPI:1104144005
Name:JOHNSON, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:JOHNSON
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 1:4134 SILVER SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:14550-9795
Mailing Address - Country:US
Mailing Address - Phone:585-786-8502
Mailing Address - Fax:
Practice Address - Street 1:1225 W STATE ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-2135
Practice Address - Country:US
Practice Address - Phone:716-372-2106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-17
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121846-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse