Provider Demographics
NPI:1568708352
Name:MASTNARDO, DIANE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:MASTNARDO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32569 SPINNAKER DR
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-2107
Mailing Address - Country:US
Mailing Address - Phone:216-789-8210
Mailing Address - Fax:
Practice Address - Street 1:36855 AMERICAN WAY
Practice Address - Street 2:SUITE A
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-4054
Practice Address - Country:US
Practice Address - Phone:216-789-8210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-24
Last Update Date:2012-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.008776225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist