Provider Demographics
NPI:1326561135
Name:DUCKWORTH, VIRGINIA DIANE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:DIANE
Last Name:DUCKWORTH
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3708 FIELDWORTH RD
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39562-8833
Mailing Address - Country:US
Mailing Address - Phone:228-623-1897
Mailing Address - Fax:
Practice Address - Street 1:168 MOBILE INFIRMARY BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-3510
Practice Address - Country:US
Practice Address - Phone:251-433-2360
Practice Address - Fax:251-433-1917
Is Sole Proprietor?:No
Enumeration Date:2017-07-24
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902189363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner