Basic Information
| Provider Information | |||||||||
| NPI: | 1285674085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ZELLEY | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | DIANE | ||||||||
| OtherMiddleName: | ZELLEY | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9315 GRAVELLY LAKE DR SW | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984991574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535815200 | ||||||||
| FaxNumber: | 2535815203 | ||||||||
| Practice Location | |||||||||
| Address1: | 8011 112TH STREET CT E | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983737814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535815200 | ||||||||
| FaxNumber: | 2535815203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT00005637 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 5022 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8930588 | 01 | WA | L&I CRIME VICTIMS PROGRAM | OTHER | ZE9838 | 01 | WA | REGENCE BLUESHIELD | OTHER | 8346934 | 05 | WA | MEDICAID | 31772 | 01 | WA | LABOR & INDUSTRIES | OTHER |