Provider Demographics
NPI:1700944568
Name:KORZENIEWSKI, DIANE BARDINA
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:BARDINA
Last Name:KORZENIEWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 WATUGA DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-1549
Mailing Address - Country:US
Mailing Address - Phone:770-287-1689
Mailing Address - Fax:
Practice Address - Street 1:545 OLD NORCROSS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3389
Practice Address - Country:US
Practice Address - Phone:678-377-2833
Practice Address - Fax:678-377-2882
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003986225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA183063315AMedicaid
GA340243OtherWELLCARE-AAKTS
GA10037631OtherAMERIGROUP-AAKTS