=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952927709
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIANE MARIE WOOD ATC, PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2020
-----------------------------------------------------
Last Update Date | 06/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2941 INVERNESS PL
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32503-5032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-382-8021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2941 INVERNESS PL
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32503-5032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-382-8021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AL4448
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------