Provider Demographics
NPI:1447554738
Name:WALATA, DIANE DESSER (LPN)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:DESSER
Last Name:WALATA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 N WELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-3343
Mailing Address - Country:US
Mailing Address - Phone:631-943-7627
Mailing Address - Fax:631-225-1952
Practice Address - Street 1:396 N WELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-3343
Practice Address - Country:US
Practice Address - Phone:631-943-7627
Practice Address - Fax:631-225-1952
Is Sole Proprietor?:No
Enumeration Date:2010-12-31
Last Update Date:2010-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290861-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse