Provider Demographics
NPI:1881159671
Name:DIEZMO, PAMELA HANNAH TENA (PT)
Entity type:Individual
Prefix:
First Name:PAMELA HANNAH
Middle Name:TENA
Last Name:DIEZMO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16611 WAR CLOUD DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-2584
Mailing Address - Country:US
Mailing Address - Phone:949-632-4674
Mailing Address - Fax:951-807-3505
Practice Address - Street 1:16611 WAR CLOUD DR
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92551-2584
Practice Address - Country:US
Practice Address - Phone:949-632-4674
Practice Address - Fax:951-807-3505
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT42486225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist