Healthcare Provider Details

I. General information

NPI: 1972127645
Provider Name (Legal Business Name): DIONE SAMANTHA HUDSON-DOUGLAS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1995 ROUTE 17M
GOSHEN NY
10924-5231
US

IV. Provider business mailing address

1995 ROUTE 17M
GOSHEN NY
10924-5231
US

V. Phone/Fax

Practice location:
  • Phone: 845-294-1234
  • Fax: 845-294-7583
Mailing address:
  • Phone: 845-294-1234
  • Fax: 845-294-7583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF308446
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: