Basic Information
| Provider Information | |||||||||
| NPI: | 1699746792 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRODERICK | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 14890 | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122124890 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185255634 | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 WALL ST | ||||||||
| Address2: | NEW DIMENSIONS IN HEALTH CARE | ||||||||
| City: | AMSTERDAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5188432575 | ||||||||
| FaxNumber: | 5188433255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2006 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 33 3344443 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.