=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700808557
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANA MARIE FELLIN CPNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 56-45 MAIN ST NEW YORK HOSPITAL MEDICAL CENTER OF QUEENS EMERGENCY D
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-670-1231
-----------------------------------------------------
Fax | 610-617-6280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 430 EMERGENCY PRACTICE PLAN
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-668-6491
-----------------------------------------------------
Fax | 610-617-6280
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | F381269
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------