Provider Demographics
NPI:1740304781
Name:SMITH, DIANNA MAE (CPTA)
Entity type:Individual
Prefix:MRS
First Name:DIANNA
Middle Name:MAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 SE 56 AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-8858
Mailing Address - Country:US
Mailing Address - Phone:620-564-2739
Mailing Address - Fax:
Practice Address - Street 1:605 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ELLINWOOD
Practice Address - State:KS
Practice Address - Zip Code:67526-1440
Practice Address - Country:US
Practice Address - Phone:620-564-2548
Practice Address - Fax:620-564-3033
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-00771225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant