Provider Demographics
NPI:1306180369
Name:STAFFORD, DIANA FAYE (RPT)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:FAYE
Last Name:STAFFORD
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 1:8934 W ADELL ST
Mailing Address - Street 2:
Mailing Address - City:FORTVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46040-9200
Mailing Address - Country:US
Mailing Address - Phone:317-485-5266
Mailing Address - Fax:
Practice Address - Street 1:8934 W ADELL ST
Practice Address - Street 2:
Practice Address - City:FORTVILLE
Practice Address - State:IN
Practice Address - Zip Code:46040-9200
Practice Address - Country:US
Practice Address - Phone:317-485-5266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05000680A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist