Provider Demographics
NPI:1568706927
Name:WONG LAM, DIANA (PT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:WONG LAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 12TH ST N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-4528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 12TH ST N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-4528
Practice Address - Country:US
Practice Address - Phone:239-261-2554
Practice Address - Fax:239-261-4540
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-23
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26686225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist