Provider Demographics
NPI:1811445315
Name:LIBURD-SEVERIN, DIANE (RN)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:LIBURD-SEVERIN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 WHITE PINE LN
Mailing Address - Street 2:
Mailing Address - City:MACEDON
Mailing Address - State:NY
Mailing Address - Zip Code:14502
Mailing Address - Country:US
Mailing Address - Phone:315-966-0425
Mailing Address - Fax:
Practice Address - Street 1:3201 WHITE PINE LN
Practice Address - Street 2:
Practice Address - City:MACEDON
Practice Address - State:NY
Practice Address - Zip Code:14502
Practice Address - Country:US
Practice Address - Phone:315-966-0425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY501268163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse