Provider Demographics
NPI:1932302064
Name:ISHAM, DIANE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:ISHAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 CAROL LN
Mailing Address - Street 2:
Mailing Address - City:ENOLA
Mailing Address - State:PA
Mailing Address - Zip Code:17025-1809
Mailing Address - Country:US
Mailing Address - Phone:717-728-8945
Mailing Address - Fax:
Practice Address - Street 1:113 CAROL LN
Practice Address - Street 2:
Practice Address - City:ENOLA
Practice Address - State:PA
Practice Address - Zip Code:17025-1809
Practice Address - Country:US
Practice Address - Phone:717-514-1498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT001735E2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics