Provider Demographics
NPI:1629318332
Name:AMENDOLA, DIANE L (LMT)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:L
Last Name:AMENDOLA
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:PO BOX 2551
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32616-2551
Mailing Address - Country:US
Mailing Address - Phone:352-342-6598
Mailing Address - Fax:
Practice Address - Street 1:13539 NW 137TH PL
Practice Address - Street 2:
Practice Address - City:ALACHUA
Practice Address - State:FL
Practice Address - Zip Code:32615-6203
Practice Address - Country:US
Practice Address - Phone:352-342-6598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA59846225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist