Healthcare Provider Details

I. General information

NPI: 1538809827
Provider Name (Legal Business Name): DIANA HENSLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 MARKET ST UNIT 302
ST AUGUSTINE FL
32095-8804
US

IV. Provider business mailing address

701 MARKET ST UNIT 302
ST AUGUSTINE FL
32095-8804
US

V. Phone/Fax

Practice location:
  • Phone: 904-698-9227
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number29413
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: