Provider Demographics
NPI:1891358180
Name:DUFRESNE, DIANE KENDRICK (LMT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:KENDRICK
Last Name:DUFRESNE
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 1:1151 S KIMBROUGH AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-1624
Mailing Address - Country:US
Mailing Address - Phone:417-370-0662
Mailing Address - Fax:
Practice Address - Street 1:1200 E WOODHURST DR STE Q
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4240
Practice Address - Country:US
Practice Address - Phone:417-877-1300
Practice Address - Fax:417-877-1335
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018006551225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist