Provider Demographics
NPI:1942894209
Name:KWON, DIANE KYUNG-AH
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:KYUNG-AH
Last Name:KWON
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 1:51385 SW OLD PORTLAND RD STE E
Mailing Address - Street 2:
Mailing Address - City:SCAPPOOSE
Mailing Address - State:OR
Mailing Address - Zip Code:97056-4062
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51385 SW OLD PORTLAND RD STE E
Practice Address - Street 2:
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056-4062
Practice Address - Country:US
Practice Address - Phone:503-446-6532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-26
Last Update Date:2021-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR63849225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist