Provider Demographics
NPI:1356086680
Name:SHARP, DIAMOND R (LMT)
Entity Type:Individual
Prefix:
First Name:DIAMOND
Middle Name:R
Last Name:SHARP
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2894 N YEIBITCHAI RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-3996
Mailing Address - Country:US
Mailing Address - Phone:928-848-6286
Mailing Address - Fax:
Practice Address - Street 1:8200 E JACQUE DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-6172
Practice Address - Country:US
Practice Address - Phone:928-277-8715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24760225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty