Provider Demographics
NPI:1932670247
Name:DIAZ, GLENDA LAVERNE (FNP)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:LAVERNE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 SPRING BOK LN
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-0691
Mailing Address - Country:US
Mailing Address - Phone:229-224-4793
Mailing Address - Fax:
Practice Address - Street 1:41 SPRING BOK LN
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-0691
Practice Address - Country:US
Practice Address - Phone:229-224-4793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-12
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN155906363LF0000X
FLAPRN11002023363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN155906OtherNEW GRADUATED FAMILYNURSE PRACTITIONER