Provider Demographics
NPI:1477670990
Name:PANTANO, DIANA (PT,DPT)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:
Last Name:PANTANO
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:114 SANDHILL DR
Practice Address - Street 2:SUITE 103
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-5805
Practice Address - Country:US
Practice Address - Phone:302-285-0700
Practice Address - Fax:302-285-0701
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT018497225100000X
DEJ10002003225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE392674ZBSXMedicare PIN
DEG00716Medicare PIN