Provider Demographics
NPI:1578632808
Name:SPIVA, DIANE L (CRNP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:SPIVA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1557 JANMAR RD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-5686
Mailing Address - Country:US
Mailing Address - Phone:678-344-8900
Mailing Address - Fax:678-666-5201
Practice Address - Street 1:10730 MEDLOCK BRIDGE RD STE 110
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-2638
Practice Address - Country:US
Practice Address - Phone:678-344-8900
Practice Address - Fax:678-666-5201
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-117580363LA2200X, 363LF0000X, 363LW0102X, 363LW0102X, 363LX0001X
KS55532367500000X, 367500000X
GARN278076363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN278076OtherRN LICENSE
GARN278076OtherAPRN LICENSE
AL1-117580OtherRN LICENSE
KS55532OtherRNA LICENSE
AL1-117580OtherCRNP LICENSE
KS1391784012OtherRN LICENSE