Healthcare Provider Details

I. General information

NPI: 1275089666
Provider Name (Legal Business Name): MRS. DIAN SANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 OCEAN AVE 6TH FLOOR
BROOKLYN NY
11235-3202
US

IV. Provider business mailing address

570 W 204TH ST
NEW YORK NY
10034-4008
US

V. Phone/Fax

Practice location:
  • Phone: 718-336-5123
  • Fax:
Mailing address:
  • Phone: 718-336-5123
  • Fax: 718-336-5137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF340966-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: