Healthcare Provider Details

I. General information

NPI: 1205422649
Provider Name (Legal Business Name): DIANE A COLLINS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2020
Last Update Date: 11/05/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W 168TH ST PH 5-505
NEW YORK NY
10032-3720
US

IV. Provider business mailing address

2424 HURON CIR
KISSIMMEE FL
34746-3437
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-6494
  • Fax:
Mailing address:
  • Phone: 754-207-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11009758
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number353246
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: