Provider Demographics
NPI:1124595483
Name:ROYALL, DIANE (LMT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:ROYALL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10111 MLK JR HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-4231
Mailing Address - Country:US
Mailing Address - Phone:301-664-0505
Mailing Address - Fax:
Practice Address - Street 1:10111 MLK HWY STE 101
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-4231
Practice Address - Country:US
Practice Address - Phone:240-474-8214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-25
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13603171400000X
MD01507-24-A172V00000X
MDM05480225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171400000XOther Service ProvidersHealth & Wellness Coach
No172V00000XOther Service ProvidersCommunity Health Worker