Provider Demographics
NPI:1144497983
Name:CHADDOCK, DIANA (RN, NP)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:CHADDOCK
Suffix:
Gender:F
Credentials:RN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HAGEN DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2658
Mailing Address - Country:US
Mailing Address - Phone:585-338-2700
Mailing Address - Fax:585-242-9663
Practice Address - Street 1:30 HAGEN DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2658
Practice Address - Country:US
Practice Address - Phone:585-338-2700
Practice Address - Fax:585-242-9663
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304798363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
000933778002OtherCOMMUNITY BLUE
1144497983OtherMVP
090109000075OtherFIDELIS CARE
000933778001OtherHEALTHNOW
PO193404798OtherBLUE CHOICE
NY02976112Medicaid
1144497983OtherMVP