Provider Demographics
NPI:1609259639
Name:HAYES, DIANA TIDAL (APRN)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:TIDAL
Last Name:HAYES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950204
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0204
Mailing Address - Country:US
Mailing Address - Phone:502-425-9138
Mailing Address - Fax:502-425-9161
Practice Address - Street 1:2050 VERSAILLES RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1405
Practice Address - Country:US
Practice Address - Phone:859-257-3573
Practice Address - Fax:859-323-0096
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009431363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1126833OtherSTATE LICENSE