Provider Demographics
NPI:1790784619
Name:MCKEITHAN, DIANA M (FNP-C)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:MCKEITHAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3011
Mailing Address - Country:US
Mailing Address - Phone:910-272-3051
Mailing Address - Fax:910-738-3764
Practice Address - Street 1:101 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:NC
Practice Address - Zip Code:28340-1951
Practice Address - Country:US
Practice Address - Phone:910-628-0655
Practice Address - Fax:910-628-0158
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201754363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2809032DMedicare ID - Type Unspecified
NCP94531Medicare UPIN