Healthcare Provider Details

I. General information

NPI: 1053686873
Provider Name (Legal Business Name): DIEDRIAN CLARKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2012
Last Update Date: 12/17/2025
Certification Date:
Deactivation Date: 07/30/2013
Reactivation Date: 12/17/2025

III. Provider practice location address

1524 MAX WAY
FISHKILL NY
12524-3942
US

IV. Provider business mailing address

1524 MAX WAY
FISHKILL NY
12524-3942
US

V. Phone/Fax

Practice location:
  • Phone: 914-439-7815
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number649609-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: