Provider Demographics
NPI:1952746182
Name:BICKERTON, DIANNE SMITH (NP)
Entity Type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:SMITH
Last Name:BICKERTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:DIANNE
Other - Middle Name:WEISHAUPT
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 214
Mailing Address - Street 2:6888 ROUTE 281
Mailing Address - City:PREBLE
Mailing Address - State:NY
Mailing Address - Zip Code:13141-0214
Mailing Address - Country:US
Mailing Address - Phone:607-749-4709
Mailing Address - Fax:
Practice Address - Street 1:6888 ROUTE 281
Practice Address - Street 2:
Practice Address - City:PREBLE
Practice Address - State:NY
Practice Address - Zip Code:13141-0214
Practice Address - Country:US
Practice Address - Phone:607-749-4709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302496-1363LA2200X
NYF340385-1363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology