Provider Demographics
NPI:1295252948
Name:ALONZO, DIANA NICOLE (ATC, LAT)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:NICOLE
Last Name:ALONZO
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 NEIL ARMSTRONG DR APT 2C
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-3854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1789 US HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:LOTT
Practice Address - State:TX
Practice Address - Zip Code:76656-3654
Practice Address - Country:US
Practice Address - Phone:219-604-1068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXAT79032255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program