Provider Demographics
NPI:1912887399
Name:MAYDICK YOUNGBERG, DIANE RITA (CNS)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:RITA
Last Name:MAYDICK YOUNGBERG
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 VALENCIA AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2024
Mailing Address - Country:US
Mailing Address - Phone:917-208-0976
Mailing Address - Fax:
Practice Address - Street 1:54 VALENCIA AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2024
Practice Address - Country:US
Practice Address - Phone:917-208-0976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-05
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYA271020-1364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist