Provider Demographics
NPI:1710313325
Name:IVKOVICH, DIANA (AT)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:IVKOVICH
Suffix:
Gender:F
Credentials:AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5402 HANNAH VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-3927
Mailing Address - Country:US
Mailing Address - Phone:513-939-1570
Mailing Address - Fax:
Practice Address - Street 1:5402 HANNAH VIEW DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-3927
Practice Address - Country:US
Practice Address - Phone:513-939-1570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0005392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer