Provider Demographics
NPI:1366419749
Name:AFFHOLTER, DIANE COLLEEN (LMP)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:COLLEEN
Last Name:AFFHOLTER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:LUSK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1260 BLAINE RD
Mailing Address - Street 2:
Mailing Address - City:ZILLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98953
Mailing Address - Country:US
Mailing Address - Phone:509-781-0549
Mailing Address - Fax:
Practice Address - Street 1:1120 S 4TH ST
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944
Practice Address - Country:US
Practice Address - Phone:509-837-2600
Practice Address - Fax:509-837-2291
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021310225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0201176OtherLTD