Healthcare Provider Details

I. General information

NPI: 1093845711
Provider Name (Legal Business Name): DIANE ALICIA EZERNACK P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 FERN CREEK DR
STATESVILLE NC
28625-9376
US

IV. Provider business mailing address

PO BOX 5105
BELFAST ME
04915-5100
US

V. Phone/Fax

Practice location:
  • Phone: 828-459-6824
  • Fax: 828-655-2344
Mailing address:
  • Phone: 919-220-5255
  • Fax: 919-220-6971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT32489
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP23026
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: