Provider Demographics
NPI:1740956523
Name:INGELS, DIANE (NP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:INGELS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 STRAWBERRY KNOLL CT
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2646
Mailing Address - Country:US
Mailing Address - Phone:631-235-1045
Mailing Address - Fax:
Practice Address - Street 1:375 E MAIN ST STE 9
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8418
Practice Address - Country:US
Practice Address - Phone:631-224-1593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF310318363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health