Provider Demographics
NPI:1225541063
Name:WAKEFIELD, DIANE ROSE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:ROSE
Last Name:WAKEFIELD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6113 PHEASANT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6988
Mailing Address - Country:US
Mailing Address - Phone:386-334-0183
Mailing Address - Fax:
Practice Address - Street 1:6113 PHEASANT RIDGE DR
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-6988
Practice Address - Country:US
Practice Address - Phone:386-334-0183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2019-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician