Provider Demographics
NPI:1922472869
Name:PRIDEMORE, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:PRIDEMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 N NYSSA AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-2258
Mailing Address - Country:US
Mailing Address - Phone:918-497-1068
Mailing Address - Fax:
Practice Address - Street 1:5800 E SKELLY DR
Practice Address - Street 2:SUITE 402
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6471
Practice Address - Country:US
Practice Address - Phone:918-497-1068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1140225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant