Healthcare Provider Details

I. General information

NPI: 1811445315
Provider Name (Legal Business Name): DIANE LIBURD-SEVERIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 WHITE PINE LN
MACEDON NY
14502
US

IV. Provider business mailing address

3201 WHITE PINE LN
MACEDON NY
14502
US

V. Phone/Fax

Practice location:
  • Phone: 315-966-0425
  • Fax:
Mailing address:
  • Phone: 315-966-0425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number501268
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: