Provider Demographics
NPI:1407097199
Name:TANNOUS, DIANA JEAN (PT ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:JEAN
Last Name:TANNOUS
Suffix:
Gender:F
Credentials:PT ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3565 LONE TREE LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-2241
Mailing Address - Country:US
Mailing Address - Phone:904-646-0627
Mailing Address - Fax:
Practice Address - Street 1:7807 BAYMEADOWS RD E
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9664
Practice Address - Country:US
Practice Address - Phone:904-398-4133
Practice Address - Fax:904-398-4148
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-10
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA20182225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant