Provider Demographics
NPI:1679054282
Name:DIESTEL, GILLIAN CHARLENE (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:GILLIAN
Middle Name:CHARLENE
Last Name:DIESTEL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12916 CONAMAR DR STE 103
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-2760
Mailing Address - Country:US
Mailing Address - Phone:301-665-3731
Mailing Address - Fax:
Practice Address - Street 1:12916 CONAMAR DR STE 103
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-2760
Practice Address - Country:US
Practice Address - Phone:301-655-3731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2023-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD27162225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist