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NPI Code Detail

MEDICARE: MRS. DIANA LEE SHERMAN PTA

MEDICARE: MRS. DIANA LEE SHERMAN PTA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225200000XPhysical Therapy AssistantIL

General Provider Information

NPI Number : 1720191414
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. DIANA LEE SHERMAN PTA
Provider Business Mailing Address
First Line : 16722 E LIBERTY RD
Second Line :
City : MOUNT VERNON
State : IL
Zip : 62864-7456
Country : US
Telephone Number : 618-237-7405
Fax Number :
Provider Business Practice Location Address
First Line : 1910 E MCCORD ST
Second Line :
City : CENTRALIA
State : IL
Zip : 62801-6586
Country : US
Telephone Number : 618-533-1200
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/16/2006
Last Update Date : 07/08/2007

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