MEDICARE: MS. DIANA JEAN TANNOUS PT ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	PTA20182	FL

General Provider Information

NPI Number	:	1407097199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DIANA JEAN TANNOUS PT ASSISTANT

Provider Business Mailing Address
First Line	:	3565 LONE TREE LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-2241
Country	:	US
Telephone Number	:	904-646-0627
Fax Number	:

Provider Business Practice Location Address
First Line	:	7807 BAYMEADOWS RD E
Second Line	:	SUITE 200
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-9664
Country	:	US
Telephone Number	:	904-398-4133
Fax Number	:	904-398-4148

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2009
Last Update Date	:	03/10/2009

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