Individual
DIANA ICKES
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PTA
Contact information
Practice address
11458 CAPTIVA KAY DR, RIVERVIEW, FL 33569-2057
(941) 812-8159
Mailing address
11458 CAPTIVA KAY DR, RIVERVIEW, FL 33569-2057
(941) 812-8159
Taxonomy
Speciality
Code
Description
License number
State
246Z00000X
Other Specialist/Technologist
Primary
PTA17336
FL
Other
Enumeration date
10/17/2016
Last updated
10/17/2016
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