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General NPI Number Information
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NPI Number | 1316170814
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Entity Type | Individual
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Provider Name | DIANE KAY MARCELLO PTA
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Gender | Female
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Dates
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Enumeration Date | 08/31/2009
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Last Update Date | 10/15/2012
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Provider Practice Location Address
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Address Line | 211 S CURTIS ST
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City | LAKE GENEVA
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State | WI
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Zip | 53147-2052
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Country | US
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Telephone | 262-248-3145
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Fax |
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Provider Business Mailing Address
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Address Line | W5473 BARLEY RD
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City | ELKHORN
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State | WI
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Zip | 53121-3451
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Country | US
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Telephone | 262-742-4773
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 962-19
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License Number State | WI
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