Provider Demographics
NPI:1144965278
Name:MCCRUMMEN, DIANE MICHELLE (LMT)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MICHELLE
Last Name:MCCRUMMEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MICHELLE
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2501 PANFISH DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33898-8838
Mailing Address - Country:US
Mailing Address - Phone:407-600-5755
Mailing Address - Fax:
Practice Address - Street 1:2501 PANFISH DR
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33898-8838
Practice Address - Country:US
Practice Address - Phone:407-600-5755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA64792225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist