Basic Information
| Provider Information | |||||||||
| NPI: | 1912123381 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIEHL | ||||||||
| FirstName: | KRISTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 202 AQUARIUS CIR N | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322161510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048863228 | ||||||||
| FaxNumber: | 9048863297 | ||||||||
| Practice Location | |||||||||
| Address1: | 12276 SAN JOSE BLVD STE 508 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322238618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048863228 | ||||||||
| FaxNumber: | 9048863297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251P0200X | PT23212 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | PT23212 | 01 | FL | PHYSICAL THERAPIST | OTHER |