Provider Demographics
NPI:1659632149
Name:DIEKMANN, ANNETTE LYNN (PTA)
Entity Type:Individual
Prefix:MS
First Name:ANNETTE
Middle Name:LYNN
Last Name:DIEKMANN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453-2004
Mailing Address - Country:US
Mailing Address - Phone:573-205-4817
Mailing Address - Fax:
Practice Address - Street 1:3625 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-4048
Practice Address - Country:US
Practice Address - Phone:314-771-2990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010041501225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant