MEDICARE: DIEMMAI ILUSTRE R.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WI0500X	Infusion Therapy Registered Nurse	673155	NY

General Provider Information

NPI Number	:	1013331370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIEMMAI ILUSTRE R.N.

Provider Business Mailing Address
First Line	:	3030 MIDDLETOWN RD APT 3G
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-5360
Country	:	US
Telephone Number	:	832-630-3354
Fax Number	:

Provider Business Practice Location Address
First Line	:	1315 YORK AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10021-5304
Country	:	US
Telephone Number	:	212-746-5789
Fax Number	:	212-746-8144

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2014
Last Update Date	:	02/06/2014

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