Provider Demographics
NPI:1164649927
Name:MCCULLER, DIANE RENEE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:RENEE
Last Name:MCCULLER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7925 YOUREE DR
Mailing Address - Street 2:SUITE 280A
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5538
Mailing Address - Country:US
Mailing Address - Phone:318-798-6833
Mailing Address - Fax:318-798-6835
Practice Address - Street 1:7925 YOUREE DR
Practice Address - Street 2:SUITE 280A
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5538
Practice Address - Country:US
Practice Address - Phone:318-798-6833
Practice Address - Fax:318-798-6835
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN051830163W00000X
LAAPL-APO 1867363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
4C720C413Medicare ID - Type Unspecified