Healthcare Provider Details

I. General information

NPI: 1598856601
Provider Name (Legal Business Name): DIANE ELIZABETH PRIMAVERA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 JEFFERSON ST SUITE 1
MONTICELLO NY
12701-1122
US

IV. Provider business mailing address

PO BOX 421 CRMC PHYSICIAN SERVICES
HARRIS NY
12742-0421
US

V. Phone/Fax

Practice location:
  • Phone: 845-794-7897
  • Fax: 845-794-1756
Mailing address:
  • Phone: 845-794-9864
  • Fax: 845-794-9868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberF333105
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF333105
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberF333105
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: