Healthcare Provider Details

I. General information

NPI: 1003221326
Provider Name (Legal Business Name): DIANE YACIUK RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2014
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N WASHINGTON ST STE 2300
HERKIMER NY
13350-1299
US

IV. Provider business mailing address

301 N WASHINGTON ST STE 2300
HERKIMER NY
13350-1299
US

V. Phone/Fax

Practice location:
  • Phone: 315-867-1176
  • Fax: 315-867-1612
Mailing address:
  • Phone: 315-867-1176
  • Fax: 315-867-1612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number481275
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: