Provider Demographics
NPI:1811161607
Name:BRISTOW, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BRISTOW
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-3251
Practice Address - Street 1:1812 MARSH RD
Practice Address - Street 2:SUITE 505
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4581
Practice Address - Country:US
Practice Address - Phone:302-475-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEU1-0001030225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEP01084211OtherMEDICARE RAILROAD
DEP01084211OtherMEDICARE RAILROAD
MD236331ZBL8Medicare PIN