Provider Demographics
NPI:1306887732
Name:JOHNSON, DIANE GAMMON
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:GAMMON
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:GAMMON
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OT
Mailing Address - Street 1:3455 CANYON DE FLORES
Mailing Address - Street 2:SUITE B
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-5380
Mailing Address - Country:US
Mailing Address - Phone:520-803-9727
Mailing Address - Fax:520-378-2683
Practice Address - Street 1:3455 CANYON DE FLORES
Practice Address - Street 2:SUITE B
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85650
Practice Address - Country:US
Practice Address - Phone:520-803-9727
Practice Address - Fax:502-378-2683
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119003467225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05501Medicare PIN