Provider Demographics
NPI:1861759474
Name:ANDERSON, DIANE MICHELLE (APN)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MICHELLE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:PROF
Other - First Name:DIANE
Other - Middle Name:MICHELLE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APN
Mailing Address - Street 1:978 BELLE AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-2613
Mailing Address - Country:US
Mailing Address - Phone:201-370-4401
Mailing Address - Fax:
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1914
Practice Address - Country:US
Practice Address - Phone:201-996-2218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00370800363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health