Provider Demographics
NPI:1538380217
Name:ANTONACCI, DIANNA L (PT, MBA)
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:L
Last Name:ANTONACCI
Suffix:
Gender:F
Credentials:PT, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7231 TALL OAK CT
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129
Mailing Address - Country:US
Mailing Address - Phone:314-846-9653
Mailing Address - Fax:
Practice Address - Street 1:7231 TALL OAK CT
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129
Practice Address - Country:US
Practice Address - Phone:314-846-9653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01009225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist