Healthcare Provider Details

I. General information

NPI: 1407097199
Provider Name (Legal Business Name): DIANA JEAN TANNOUS PT ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2009
Last Update Date: 03/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7807 BAYMEADOWS RD E SUITE 200
JACKSONVILLE FL
32256-9664
US

IV. Provider business mailing address

3565 LONE TREE LN
JACKSONVILLE FL
32216-2241
US

V. Phone/Fax

Practice location:
  • Phone: 904-398-4133
  • Fax: 904-398-4148
Mailing address:
  • Phone: 904-646-0627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA20182
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: