Healthcare Provider Details

I. General information

NPI: 1043331507
Provider Name (Legal Business Name): LYNDA SUSAN DIANGELO P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

871 RIDGEWAY LOOP RD STE 100
MEMPHIS TN
38120-4026
US

IV. Provider business mailing address

871 RIDGEWAY LOOP RD
MEMPHIS TN
38120-4038
US

V. Phone/Fax

Practice location:
  • Phone: 901-759-1282
  • Fax: 901-759-1290
Mailing address:
  • Phone: 901-759-1282
  • Fax: 901-759-1290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3462
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: