Provider Demographics
NPI:1407376254
Name:DIMINO, ELIZABETH MCTAGGART (NP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MCTAGGART
Last Name:DIMINO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ROSE
Other - Last Name:MCTAGGART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 BAPTIST BLVD STE 301
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2006
Practice Address - Country:US
Practice Address - Phone:662-244-2550
Practice Address - Fax:662-244-2553
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901954363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology