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General NPI Number Information
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NPI Number | 1871118505
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Entity Type | Individual
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Provider Name | DIAMOND MUNGROO
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Gender | Female
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Dates
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Enumeration Date | 06/09/2020
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Last Update Date | 01/03/2026
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Provider Practice Location Address
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Address Line | 97 HEFNER ST
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City | EAST ELLIJAY
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State | GA
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Zip | 30540-8268
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Country | US
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Telephone | 706-635-1440
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Fax |
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Provider Business Mailing Address
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Address Line | 316 PLANTATION CIR
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-5407
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Country | US
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Telephone | 404-901-5755
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT004177
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT017813
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License Number State | GA
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