Healthcare Provider Details

I. General information

NPI: 1598015489
Provider Name (Legal Business Name): DIANA KAYE PRYLUCKI-RUGOLO M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DIANA KAYE PRYLUCKI M.S

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 FRANKLIN PL
OCEANSIDE NY
11572-1313
US

IV. Provider business mailing address

30 FRANKLIN PL
OCEANSIDE NY
11572-1313
US

V. Phone/Fax

Practice location:
  • Phone: 516-263-2349
  • Fax:
Mailing address:
  • Phone: 516-263-2349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1123143
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: