Provider Demographics
NPI:1063038792
Name:ANDERSON, DIANNA MARIE
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 OLD SANDY CREEK RD STE B
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4546
Mailing Address - Country:US
Mailing Address - Phone:678-834-7325
Mailing Address - Fax:
Practice Address - Street 1:101 OLD SANDY CREEK RD STE B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4546
Practice Address - Country:US
Practice Address - Phone:678-834-7325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care