MEDICARE: DIANE M CUERVO LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	314891-1	NY
2	164W00000X	Licensed Practical Nurse	26NP06981300	NJ

General Provider Information

NPI Number	:	1235674706
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE M CUERVO LPN

Provider Business Mailing Address
First Line	:	9 DUDLEY AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-4003
Country	:	US
Telephone Number	:	718-496-8678
Fax Number	:

Provider Business Practice Location Address
First Line	:	9 DUDLEY AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-4003
Country	:	US
Telephone Number	:	718-496-8678
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2016
Last Update Date	:	12/19/2016

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