Provider Demographics
NPI:1821165119
Name:SHKOLNIK, DIANA (LAC)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:SHKOLNIK
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1647 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-3043
Mailing Address - Country:US
Mailing Address - Phone:415-665-1111
Mailing Address - Fax:415-665-1111
Practice Address - Street 1:2886 GEARY BLVD
Practice Address - Street 2:SUITE #204
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-3454
Practice Address - Country:US
Practice Address - Phone:415-771-2389
Practice Address - Fax:415-771-2389
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225700000X
CAAC7626171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Not Answered171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9638135Medicaid