Basic Information
| Provider Information | |||||||||
| NPI: | 1508847591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EPPLEIN | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVIDSON | ||||||||
| OtherFirstName: | DIANNE | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 818 NEWTOWN RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234621116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574738016 | ||||||||
| FaxNumber: | 7574733580 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 NEWTOWN RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234621116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574738016 | ||||||||
| FaxNumber: | 7574733580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305 000587 | VA | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225000000X | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotic Fitter |
ID Information
| ID | Type | State | Issuer | Description | 64 00313 | 01 | UNITED HEALTH CARE | OTHER | 35062 | 01 | OPTIMA | OTHER | 5369690 | 01 | AETNA | OTHER | 5275769 | 01 | AETNA GROUP | OTHER | 436752 | 01 | ANTHEM BLUE CROSS | OTHER | 007328 | 01 | ANTHEM BLUE CROSS GROUP | OTHER | 4980093 | 01 | VIRGINIA PREMIER HEALTH P | OTHER | 4980093 | 05 | VA | MEDICAID | 11230312 | 01 | CAQH | OTHER | 350034 | 01 | OPTIMA GROUP | OTHER | 9116460 | 01 | VA | MEDICAID | OTHER |