Provider Demographics
NPI:1780017004
Name:STAKOE, DIANE (LMBT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:STAKOE
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8384 SIX FORKS RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-5079
Mailing Address - Country:US
Mailing Address - Phone:919-349-2673
Mailing Address - Fax:
Practice Address - Street 1:8384 SIX FORKS RD
Practice Address - Street 2:SUITE 203
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-5079
Practice Address - Country:US
Practice Address - Phone:919-349-2673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-11
Last Update Date:2013-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7499225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist