Provider Demographics
NPI:1679630123
Name:CUNNINGHAM, DIANNE T
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:T
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANNE
Other - Middle Name:T
Other - Last Name:VONTTEGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:PO BOX 20
Mailing Address - Street 2:
Mailing Address - City:SMALLWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:12778
Mailing Address - Country:US
Mailing Address - Phone:845-796-0931
Mailing Address - Fax:845-796-0931
Practice Address - Street 1:437 PARKSVILLE ROAD
Practice Address - Street 2:
Practice Address - City:PARKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12768
Practice Address - Country:US
Practice Address - Phone:845-292-3296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248076164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse