Provider Demographics
NPI:1730265463
Name:IWANIEC, DIANE JENAVE (DC)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:JENAVE
Last Name:IWANIEC
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:JENAVE
Other - Last Name:MACGAURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:133 COLUMBIA TURNPIKE
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144
Mailing Address - Country:US
Mailing Address - Phone:518-432-7951
Mailing Address - Fax:518-432-7421
Practice Address - Street 1:133 COLUMBIA TURNPIKE
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:NY
Practice Address - Zip Code:12144
Practice Address - Country:US
Practice Address - Phone:518-432-7951
Practice Address - Fax:518-432-7421
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX005916111N00000X
VA0104001439111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10066230OtherCDPHP
NYX5P921OtherEBCBS
NYCO5916OtherWCB
NY10066230OtherCDPHP
NYDD2511Medicare ID - Type Unspecified