Provider Demographics
NPI:1558480640
Name:BURDICK, DIANA MOREE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:MOREE
Last Name:BURDICK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:DIANA
Other - Middle Name:MOREE
Other - Last Name:STOUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:102 NORTH FISHER
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:MO
Mailing Address - Zip Code:65084
Mailing Address - Country:US
Mailing Address - Phone:573-378-2349
Mailing Address - Fax:573-376-2350
Practice Address - Street 1:102 NORTH FISHER
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:MO
Practice Address - Zip Code:65084
Practice Address - Country:US
Practice Address - Phone:573-378-2349
Practice Address - Fax:573-376-2350
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO056572363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO423630409Medicaid
MO423630409Medicaid