Provider Demographics
NPI:1912916792
Name:FITZGERALD, DIANA LYNN (NP, CNM)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:NP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3153
Mailing Address - Country:US
Mailing Address - Phone:203-272-1811
Mailing Address - Fax:315-363-9382
Practice Address - Street 1:675 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-3153
Practice Address - Country:US
Practice Address - Phone:203-272-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY483641-1163W00000X
NY420822363L00000X
NY28-001237367A00000X
NYF001237367A00000X
CT000518176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02806357Medicaid