Provider Demographics
NPI:1093845711
Name:EZERNACK, DIANE ALICIA (PT)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:ALICIA
Last Name:EZERNACK
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5105
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5100
Mailing Address - Country:US
Mailing Address - Phone:919-220-5255
Mailing Address - Fax:919-220-6971
Practice Address - Street 1:1414 FERN CREEK DR
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-9376
Practice Address - Country:US
Practice Address - Phone:828-459-6824
Practice Address - Fax:828-655-2344
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT32489225100000X
NCP23026225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP23026OtherPT LICENSE
LA4H5297545Medicare PIN
LA4H529Medicare PIN