Provider Demographics
NPI:1932734944
Name:SMULLIGAN, DIANE M
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:SMULLIGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:KOWALSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:65 N VINE ST
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201-5847
Mailing Address - Country:US
Mailing Address - Phone:570-233-0955
Mailing Address - Fax:
Practice Address - Street 1:149 S HUNTER HWY
Practice Address - Street 2:
Practice Address - City:DRUMS
Practice Address - State:PA
Practice Address - Zip Code:18222-2422
Practice Address - Country:US
Practice Address - Phone:570-788-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI001734225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant