Provider Demographics
NPI:1740549724
Name:KOLOTYLO-FARISH, DIANE MARIE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:KOLOTYLO-FARISH
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 1:164 FREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-2237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:392 PEARL ST
Practice Address - Street 2:SUITE 400
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-2202
Practice Address - Country:US
Practice Address - Phone:716-881-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY259439163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse