Provider Demographics
NPI:1417147844
Name:PARKS, DIANE MUDGE (MSN,WHNP)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MUDGE
Last Name:PARKS
Suffix:
Gender:F
Credentials:MSN,WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S MAIN ST STE 113
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-3228
Mailing Address - Country:US
Mailing Address - Phone:704-799-5433
Mailing Address - Fax:704-706-2446
Practice Address - Street 1:500 S MAIN ST STE 113
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-3228
Practice Address - Country:US
Practice Address - Phone:704-799-5433
Practice Address - Fax:704-706-2446
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC110557163W00000X
NC940100363LW0102X, 363LF0000X
NC337367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2594285Medicare PIN