Basic Information
| Provider Information | |||||||||
| NPI: | 1598856601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRIMAVERA | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | CRMC PHYSICIAN SERVICES | ||||||||
| City: | HARRIS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127420421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457949864 | ||||||||
| FaxNumber: | 8457949868 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 JEFFERSON ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MONTICELLO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 127011122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457947897 | ||||||||
| FaxNumber: | 8457941756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 03/04/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | F333105 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 363L00000X | F333105 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LX0001X | F333105 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 02391293 | 05 | NY | MEDICAID |