Provider Demographics
NPI:1679846653
Name:SMITH, DIANE FULPER (FNP)
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:FULPER
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2907 TIDAL DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4370
Mailing Address - Country:US
Mailing Address - Phone:804-627-5360
Mailing Address - Fax:804-627-5370
Practice Address - Street 1:8580 MAGELLAN PKWY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23227-1149
Practice Address - Country:US
Practice Address - Phone:804-627-5360
Practice Address - Fax:804-627-5370
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024070952363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily