Provider Demographics
NPI:1093832388
Name:DILLARD, DIANA LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:DILLARD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1385 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-5130
Mailing Address - Country:US
Mailing Address - Phone:252-537-9176
Mailing Address - Fax:252-537-6851
Practice Address - Street 1:1385 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-5130
Practice Address - Country:US
Practice Address - Phone:252-537-9176
Practice Address - Fax:252-537-6851
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0050-02800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5002800OtherLICENSE
NC7004833Medicaid