Provider Demographics
NPI:1457396699
Name:GAINES, DIANNE SWANSON (PT)
Entity Type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:SWANSON
Last Name:GAINES
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 1:125 RIVERS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:EAST PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32131-4310
Mailing Address - Country:US
Mailing Address - Phone:386-328-3030
Mailing Address - Fax:
Practice Address - Street 1:927 S STATE ROAD 19
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-9397
Practice Address - Country:US
Practice Address - Phone:386-336-9028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL225100000X
2251P0200X
FLPT 0003378225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL881063000Medicaid