Provider Demographics
NPI:1609684893
Name:GORELIK, DIANA (APRN)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:GORELIK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 WYE RD
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-0013
Mailing Address - Country:US
Mailing Address - Phone:718-864-4658
Mailing Address - Fax:
Practice Address - Street 1:114 WYE RD
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-0013
Practice Address - Country:US
Practice Address - Phone:718-864-4658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11036592363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner