Provider Demographics
NPI:1992007108
Name:OTWELL, DIANA L (LMP)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:L
Last Name:OTWELL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33650 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6754
Mailing Address - Country:US
Mailing Address - Phone:209-740-6827
Mailing Address - Fax:
Practice Address - Street 1:33650 6TH AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6754
Practice Address - Country:US
Practice Address - Phone:209-740-6827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60179290174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist