Provider Demographics
NPI:1740835289
Name:GHEKIERE, DIANA RENEE (PTA)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:RENEE
Last Name:GHEKIERE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22315 BERRING AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-9798
Mailing Address - Country:US
Mailing Address - Phone:218-428-0306
Mailing Address - Fax:
Practice Address - Street 1:1601 SAINT FRANCIS AVE STE 200
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-3385
Practice Address - Country:US
Practice Address - Phone:952-428-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2332225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant