Provider Demographics
NPI:1265199244
Name:KANJILAL, DIANE GISELLE (FNP)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:GISELLE
Last Name:KANJILAL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:DIANE
Other - Middle Name:GISELLE
Other - Last Name:ANANOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:55 FRUIT ST # 504F
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2696
Mailing Address - Country:US
Mailing Address - Phone:617-643-9958
Mailing Address - Fax:
Practice Address - Street 1:55 FRUIT ST # 504F
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2696
Practice Address - Country:US
Practice Address - Phone:617-643-9958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-24
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2310852363L00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner