Provider Demographics
NPI:1538417506
Name:SMITH, DIANNE MARIE (MS, RCEP)
Entity type:Individual
Prefix:MS
First Name:DIANNE
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, RCEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 12TH ST
Mailing Address - Street 2:
Mailing Address - City:CLAY CENTER
Mailing Address - State:KS
Mailing Address - Zip Code:67432-2232
Mailing Address - Country:US
Mailing Address - Phone:785-632-2144
Mailing Address - Fax:785-632-5031
Practice Address - Street 1:617 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:CLAY CENTER
Practice Address - State:KS
Practice Address - Zip Code:67432-1564
Practice Address - Country:US
Practice Address - Phone:785-632-2144
Practice Address - Fax:785-632-5031
Is Sole Proprietor?:No
Enumeration Date:2012-08-24
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1000565224Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise Physiologist