Provider Demographics
NPI:1043679079
Name:DOUGLASS, DIANNA FORREST (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:DIANNA
Middle Name:FORREST
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 COUNTY ROAD 373
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965-3740
Mailing Address - Country:US
Mailing Address - Phone:662-202-4705
Mailing Address - Fax:
Practice Address - Street 1:152 HIGHWAY 7 S
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5392
Practice Address - Country:US
Practice Address - Phone:662-234-7521
Practice Address - Fax:662-236-3071
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-18
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901761163WP0808X
MS903689363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health