Provider Demographics
NPI:1932892148
Name:KELLER, DIANA MARIA (PTA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIA
Last Name:KELLER
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 1:333 GLENMOOR DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6492
Mailing Address - Country:US
Mailing Address - Phone:260-415-6658
Mailing Address - Fax:
Practice Address - Street 1:333 GLENMOOR DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6492
Practice Address - Country:US
Practice Address - Phone:260-415-6658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06005065A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant