Provider Demographics
NPI:1942598297
Name:FESTER, DIANE (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:FESTER
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 1:11140 HIGHWAY 55
Mailing Address - Street 2:SUITE C
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-6016
Mailing Address - Country:US
Mailing Address - Phone:763-595-0812
Mailing Address - Fax:763-595-0824
Practice Address - Street 1:11140 HIGHWAY 55
Practice Address - Street 2:SUITE C
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-6071
Practice Address - Country:US
Practice Address - Phone:763-595-0812
Practice Address - Fax:763-595-0824
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4211225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics