Healthcare Provider Details

I. General information

NPI: 1790338382
Provider Name (Legal Business Name): DIANE HAYNES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3712 PRINCE ST STE 3C
FLUSHING NY
11354-4650
US

IV. Provider business mailing address

419 COOLIDGE AVE
ROCKVILLE CENTRE NY
11570-3307
US

V. Phone/Fax

Practice location:
  • Phone: 718-380-7800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number358027
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number708471
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: