Provider Demographics
NPI:1306008081
Name:JANICKI, DIANE (RPT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:JANICKI
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:PO BOX 1497
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-1497
Mailing Address - Country:US
Mailing Address - Phone:307-875-8492
Mailing Address - Fax:307-875-7389
Practice Address - Street 1:140 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935-6178
Practice Address - Country:US
Practice Address - Phone:307-875-8492
Practice Address - Fax:307-875-7389
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY110936700Medicaid
WY110936700Medicaid