Provider Demographics
NPI:1275549891
Name:SMITH, DIANA LYNN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:MISS
Other - First Name:DIANA
Other - Middle Name:LYNN
Other - Last Name:KEAST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:11481 SW HALL BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8403
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-443-1402
Practice Address - Street 1:23327 EAST APPLEWAY
Practice Address - Street 2:STE 160
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-5038
Practice Address - Country:US
Practice Address - Phone:509-891-2258
Practice Address - Fax:509-891-2094
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007834225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1275549891Medicaid
WA8861149Medicare PIN