Provider Demographics
NPI:1194491779
Name:BADALOVA, DIANA (NP)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:BADALOVA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6635 SAUNDERS ST
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4635
Mailing Address - Country:US
Mailing Address - Phone:917-502-7875
Mailing Address - Fax:
Practice Address - Street 1:6635 SAUNDERS ST
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-4635
Practice Address - Country:US
Practice Address - Phone:917-502-7875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310298363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health