Provider Demographics
NPI:1699102723
Name:DOMAINGUE, DIANA MARIE (DPT)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:DOMAINGUE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5303 BLACKBURN CT
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-6171
Mailing Address - Country:US
Mailing Address - Phone:904-254-0452
Mailing Address - Fax:
Practice Address - Street 1:1181 BLACKWOOD AVE
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-4518
Practice Address - Country:US
Practice Address - Phone:407-292-0073
Practice Address - Fax:407-292-9666
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT28445225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist