Provider Demographics
NPI:1982807475
Name:ANDRADE, DIANA (PTA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:ANDRADE
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 1:136 MADELIA PL
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-5795
Mailing Address - Country:US
Mailing Address - Phone:704-657-7348
Mailing Address - Fax:
Practice Address - Street 1:550 GLENWOOD DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2876
Practice Address - Country:US
Practice Address - Phone:704-664-7494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3750225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant