Healthcare Provider Details

I. General information

NPI: 1619454139
Provider Name (Legal Business Name): DIANE ELIZABETH WAHNE PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 05/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 W ROE BLVD
PATCHOGUE NY
11772-2569
US

IV. Provider business mailing address

15 NEW MILL RD
SMITHTOWN NY
11787-3323
US

V. Phone/Fax

Practice location:
  • Phone: 631-493-7636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number402469
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: