Provider Demographics
NPI:1417312489
Name:VESTAL, DIANE A (OTA/L)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:A
Last Name:VESTAL
Suffix:
Gender:F
Credentials:OTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 TAPLOW RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-3540
Mailing Address - Country:US
Mailing Address - Phone:410-530-1645
Mailing Address - Fax:
Practice Address - Street 1:1320 WINDLASS DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21220-4100
Practice Address - Country:US
Practice Address - Phone:410-918-2139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00725224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant