Provider Demographics
NPI:1083278311
Name:KIRKLAND, COURTNEY DIANA
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:DIANA
Last Name:KIRKLAND
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:PO BOX 2347
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-6161
Mailing Address - Country:US
Mailing Address - Phone:940-626-8073
Mailing Address - Fax:940-626-8137
Practice Address - Street 1:2351 S FM 51 STE 100
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3778
Practice Address - Country:US
Practice Address - Phone:940-626-8073
Practice Address - Fax:940-626-8137
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-22
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA5976963363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8NL737OtherBCBSTX
TXPENDINGMedicaid