Provider Demographics
NPI:1982253720
Name:GAINES, DIANA ANDREA (LAC)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:ANDREA
Last Name:GAINES
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 BURNS ST APT 420
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5247
Mailing Address - Country:US
Mailing Address - Phone:917-686-4664
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY STE 303
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-8155
Practice Address - Country:US
Practice Address - Phone:917-686-4664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006568-01171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty