Provider Demographics
NPI:1720161243
Name:OBRIEN, DIANA HOWELL (PT MPT)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:HOWELL
Last Name:OBRIEN
Suffix:
Gender:F
Credentials:PT MPT
Other - Prefix:MS
Other - First Name:DIANA
Other - Middle Name:C
Other - Last Name:HOWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT MPT
Mailing Address - Street 1:PO BOX 729
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:WY
Mailing Address - Zip Code:83014-0729
Mailing Address - Country:US
Mailing Address - Phone:307-699-7667
Mailing Address - Fax:307-733-4955
Practice Address - Street 1:1116 MAPLE WAY
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83002-9725
Practice Address - Country:US
Practice Address - Phone:307-733-7037
Practice Address - Fax:307-733-4955
Is Sole Proprietor?:No
Enumeration Date:2006-10-21
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY845225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY312610OtherWY BCBS
WY118929800Medicaid
WYW307976Medicare PIN
WY118929800Medicaid