Provider Demographics
NPI:1104356302
Name:DIAZ, BETSY (FNP-C)
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 1ST AVE N
Mailing Address - Street 2:UNIT 3
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35203-1866
Mailing Address - Country:US
Mailing Address - Phone:205-545-5088
Mailing Address - Fax:
Practice Address - Street 1:67 W RAILROAD ST
Practice Address - Street 2:
Practice Address - City:SHELLMAN
Practice Address - State:GA
Practice Address - Zip Code:39886-3100
Practice Address - Country:US
Practice Address - Phone:229-679-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-01-25
Deactivation Date:2021-09-18
Deactivation Code:
Reactivation Date:2021-10-18
Provider Licenses
StateLicense IDTaxonomies
GARN133959363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner