Provider Demographics
NPI:1598536310
Name:FORT, DIANNA (NP)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:
Last Name:FORT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 PARK TER
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:SC
Mailing Address - Zip Code:29369-8307
Mailing Address - Country:US
Mailing Address - Phone:757-952-9974
Mailing Address - Fax:
Practice Address - Street 1:111 LOVETT DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-6510
Practice Address - Country:US
Practice Address - Phone:801-869-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28250363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty