Healthcare Provider Details

I. General information

NPI: 1417197633
Provider Name (Legal Business Name): DIANNE LYNNE MAZZO ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MS. DIANNE LYNNE SECRETO-MAZZO

II. Dates (important events)

Enumeration Date: 02/27/2009
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MCCORMICK DR
PALM COAST FL
32164-2352
US

IV. Provider business mailing address

2460 OLD MOULTRIE RD STE 1
ST AUGUSTINE FL
32086-4198
US

V. Phone/Fax

Practice location:
  • Phone: 386-246-7365
  • Fax:
Mailing address:
  • Phone: 386-264-1130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95025681
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9284326
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: