Provider Demographics
NPI:1104220433
Name:TAYLOR, DIANA L (DNP, CPNP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:DNP, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 PROFESSIONAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526
Mailing Address - Country:US
Mailing Address - Phone:843-234-5678
Mailing Address - Fax:
Practice Address - Street 1:140 PROFESSIONAL PARK DRIVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526
Practice Address - Country:US
Practice Address - Phone:843-234-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18919363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics