Healthcare Provider Details

I. General information

NPI: 1922598358
Provider Name (Legal Business Name): ANDREA SUZANNE DIACONO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 E ARLINGTON BLVD
GREENVILLE NC
27858-5870
US

IV. Provider business mailing address

1540 E ARLINGTON BLVD
GREENVILLE NC
27858-5870
US

V. Phone/Fax

Practice location:
  • Phone: 252-364-2806
  • Fax: 252-364-2863
Mailing address:
  • Phone: 252-364-2806
  • Fax: 252-364-2863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP16409
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: