Provider Demographics
NPI:1285627679
Name:KEITH, DIANA LYNN (MA AT,C)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:KEITH
Suffix:
Gender:F
Credentials:MA AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8131 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4521
Mailing Address - Country:US
Mailing Address - Phone:410-774-5694
Mailing Address - Fax:
Practice Address - Street 1:EMPIRE MEDICAL BUILDING 200 HOSPITAL DRIVE
Practice Address - Street 2:CHESAPEAKE ORTHOPEADICS & SPORTS MEDICINE
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061
Practice Address - Country:US
Practice Address - Phone:410-768-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0893024782255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
6048680001Medicare NSC