Provider Demographics
NPI:1639286057
Name:TEAGARDEN, DIANE L (NP, APRN-BC, MSN)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:L
Last Name:TEAGARDEN
Suffix:
Gender:F
Credentials:NP, APRN-BC, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 EXECUTIVE PARK DR NE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2206
Mailing Address - Country:US
Mailing Address - Phone:404-778-3444
Mailing Address - Fax:404-778-4216
Practice Address - Street 1:12 EXECUTIVE PARK DR NE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2206
Practice Address - Country:US
Practice Address - Phone:404-778-3444
Practice Address - Fax:404-778-4216
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN105822363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS53697002Medicare UPIN
GA50BBCGVMedicare ID - Type Unspecified