Provider Demographics
NPI:1164602579
Name:KANE-FOURNIER, DIANE (RPT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:KANE-FOURNIER
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-3407
Mailing Address - Country:US
Mailing Address - Phone:860-886-2042
Mailing Address - Fax:860-885-1811
Practice Address - Street 1:57 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-3407
Practice Address - Country:US
Practice Address - Phone:860-886-2042
Practice Address - Fax:860-885-1811
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650000273Medicare PIN
CTC02452Medicare UPIN