=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447478805
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE RUSSELL FARNHAM P.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 W BUFFALO ST
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-4132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-272-8869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4102 GARRETT RD
-----------------------------------------------------
City | ITHACA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14850-9563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-273-3319
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 004322
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------