1093709735 NPI number — DIANA DAWN YOUNG PT

Table of content: DIANA DAWN YOUNG PT (NPI 1093709735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093709735 NPI number — DIANA DAWN YOUNG PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YOUNG
Provider First Name:
DIANA
Provider Middle Name:
DAWN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093709735
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4310 NW 117TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNRISE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33323-2669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-572-7217
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12341 NW 18TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLANTATION
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33323-2122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-478-4648
Provider Business Practice Location Address Fax Number:
954-530-5694
Provider Enumeration Date:
09/08/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT13623 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)