Provider Demographics
NPI:1487608733
Name:GANNON, DIANE (PT)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 BUTTERNUT DR
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-6951
Mailing Address - Country:US
Mailing Address - Phone:401-295-9767
Mailing Address - Fax:401-295-0230
Practice Address - Street 1:610 TEN ROD ROAD
Practice Address - Street 2:WICKFORD CHIROPRACTIC AND WELLNESS CENTER
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-6951
Practice Address - Country:US
Practice Address - Phone:401-295-9767
Practice Address - Fax:401-295-0230
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT01319225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist