Provider Demographics
NPI:1093201097
Name:DIANA, KEVIN DAVID (PTA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DAVID
Last Name:DIANA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WILLOWBAY RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-7990
Mailing Address - Country:US
Mailing Address - Phone:321-662-1174
Mailing Address - Fax:
Practice Address - Street 1:2884 WELLNESS AVE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8426
Practice Address - Country:US
Practice Address - Phone:386-774-4404
Practice Address - Fax:386-774-4496
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17272225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant