Provider Demographics
NPI:1194325662
Name:VISSER-FARTEK, DIANA LYNN (OTA16477)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:VISSER-FARTEK
Suffix:
Gender:F
Credentials:OTA16477
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23252 ROUNTREE AVE # 4
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33980-7302
Mailing Address - Country:US
Mailing Address - Phone:239-443-0511
Mailing Address - Fax:
Practice Address - Street 1:4000 KINGS HWY
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-8718
Practice Address - Country:US
Practice Address - Phone:941-255-9006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16477224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant