Provider Demographics
NPI:1851017974
Name:KIDWELL, DIANNA LYNN (APRN, AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:DIANNA
Middle Name:LYNN
Last Name:KIDWELL
Suffix:
Gender:F
Credentials:APRN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2130
Mailing Address - Country:US
Mailing Address - Phone:903-595-5486
Mailing Address - Fax:903-595-5128
Practice Address - Street 1:1133 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2130
Practice Address - Country:US
Practice Address - Phone:903-595-5486
Practice Address - Fax:903-595-5128
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX705683163W00000X
TXAP1097102363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care