Provider Demographics
NPI:1770808222
Name:KEARNEY-CAMERADA, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:KEARNEY-CAMERADA
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 1:152 MARINE WAY
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-5758
Mailing Address - Country:US
Mailing Address - Phone:718-987-4617
Mailing Address - Fax:
Practice Address - Street 1:645 ROSSVILLE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-1752
Practice Address - Country:US
Practice Address - Phone:718-967-2955
Practice Address - Fax:718-967-2978
Is Sole Proprietor?:No
Enumeration Date:2010-03-27
Last Update Date:2010-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039945-1183500000X
NJ19827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist