Provider Demographics
NPI:1750545539
Name:SONNTAG, DIANE JEANNE (LMT)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:JEANNE
Last Name:SONNTAG
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1527 143 AVE
Mailing Address - Street 2:
Mailing Address - City:TENINO
Mailing Address - State:WA
Mailing Address - Zip Code:98589
Mailing Address - Country:US
Mailing Address - Phone:360-264-5521
Mailing Address - Fax:
Practice Address - Street 1:205 CLARK PL SE
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-4062
Practice Address - Country:US
Practice Address - Phone:360-264-5521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60018972174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist