Provider Demographics
NPI:1831115096
Name:DIFONZO, CAROLYN (FNP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:DIFONZO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7350 PORTER RD
Mailing Address - Street 2:
Mailing Address - City:NIAGARA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14304-5705
Mailing Address - Country:US
Mailing Address - Phone:716-332-1644
Mailing Address - Fax:716-299-0775
Practice Address - Street 1:7350 PORTER RD
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14304-5705
Practice Address - Country:US
Practice Address - Phone:716-332-1644
Practice Address - Fax:716-299-0775
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF 334650 1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00027338407OtherUNIVERA/EXCELLUS
NY9513035OtherIHA PROVIDER ID
NY000560981002OtherBLUE CROSS /BLUE SHIELD W
NY000560981002OtherBLUE CROSS /BLUE SHIELD W
RB6650Medicare PIN