Provider Demographics
NPI:1417940784
Name:SMITH, DIANE L (FNP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 NW ATLANTIC ST
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-3562
Mailing Address - Country:US
Mailing Address - Phone:931-455-2273
Mailing Address - Fax:
Practice Address - Street 1:2008 DECHERD BLVD
Practice Address - Street 2:
Practice Address - City:DECHERD
Practice Address - State:TN
Practice Address - Zip Code:37324-3818
Practice Address - Country:US
Practice Address - Phone:931-967-0931
Practice Address - Fax:319-967-0844
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAP0000006502363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3499944Medicare ID - Type Unspecified
TNQ28264Medicare UPIN