Healthcare Provider Details

I. General information

NPI: 1659632149
Provider Name (Legal Business Name): ANNETTE LYNN DIEKMANN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 05/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3625 MAGNOLIA AVE
SAINT LOUIS MO
63110-4048
US

IV. Provider business mailing address

3011 CHESTNUT ST
CUBA MO
65453-2004
US

V. Phone/Fax

Practice location:
  • Phone: 314-771-2990
  • Fax:
Mailing address:
  • Phone: 573-205-4817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2010041501
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: