Provider Demographics
NPI:1275516254
Name:LANTAGNE, DIANE SANTOS (MPT, OCS)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:SANTOS
Last Name:LANTAGNE
Suffix:
Gender:F
Credentials:MPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 S COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4162
Mailing Address - Country:US
Mailing Address - Phone:703-778-8736
Mailing Address - Fax:
Practice Address - Street 1:1050 W PERIMETER RD
Practice Address - Street 2:
Practice Address - City:ANDREWS AFB
Practice Address - State:MD
Practice Address - Zip Code:20762-6601
Practice Address - Country:US
Practice Address - Phone:240-857-8472
Practice Address - Fax:240-857-9415
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1147952225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist