Healthcare Provider Details

I. General information

NPI: 1386832558
Provider Name (Legal Business Name): DIANA FRANCIS NIELSEN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2007
Last Update Date: 10/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 MEETING HOUSE LN
SOUTHAMPTON NY
11968-5009
US

IV. Provider business mailing address

35 LEEDS BLVD
FARMINGVILLE NY
11738-1147
US

V. Phone/Fax

Practice location:
  • Phone: 631-726-8520
  • Fax:
Mailing address:
  • Phone: 631-698-4032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number154
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: