Provider Demographics
NPI:1396759759
Name:DONOFRIO, DIANNA JEANNE (MPT)
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:JEANNE
Last Name:DONOFRIO
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:DIANNA
Other - Middle Name:JEANNE
Other - Last Name:HUETE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:18095 HIGHWAY 18
Mailing Address - Street 2:SUITE C
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307
Mailing Address - Country:US
Mailing Address - Phone:760-242-7702
Mailing Address - Fax:760-242-7571
Practice Address - Street 1:18095 HIGHWAY 18
Practice Address - Street 2:SUITE C
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-242-7702
Practice Address - Fax:760-242-7571
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23516225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0235160Medicaid
OPT235160Medicare ID - Type Unspecified
P49602Medicare UPIN