Provider Demographics
NPI:1225619851
Name:SORENSEN, DIANNA (LDO)
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 SHAKER DR STE 113
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3674
Mailing Address - Country:US
Mailing Address - Phone:859-276-2573
Mailing Address - Fax:859-276-2574
Practice Address - Street 1:715 SHAKER DR STE 113
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3674
Practice Address - Country:US
Practice Address - Phone:859-276-2573
Practice Address - Fax:859-276-2574
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY110067156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1003908849Medicaid