Provider Demographics
NPI:1407969058
Name:WIRTH, DIANE L (ANP-BC)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:L
Last Name:WIRTH
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 JANMAR RD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2103
Mailing Address - Country:US
Mailing Address - Phone:770-979-1154
Mailing Address - Fax:
Practice Address - Street 1:1525 CLIFTON RD NE
Practice Address - Street 2:SUITE 207
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-4200
Practice Address - Country:US
Practice Address - Phone:404-778-4451
Practice Address - Fax:404-778-4355
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN108564 NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health