Provider Demographics
NPI:1033405600
Name:MILLENBAUGH, DIANA GRAY (MSN, RNP, BC)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:GRAY
Last Name:MILLENBAUGH
Suffix:
Gender:F
Credentials:MSN, RNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 CAMDEN RD STE 12
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-4612
Mailing Address - Country:US
Mailing Address - Phone:870-534-4847
Mailing Address - Fax:870-534-4884
Practice Address - Street 1:3801 CAMDEN RD STE 12
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-4612
Practice Address - Country:US
Practice Address - Phone:870-534-4847
Practice Address - Fax:870-534-4884
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA02944ANP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily