Provider Demographics
NPI:1245343896
Name:COUSINS, DIANE H (APRN)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:H
Last Name:COUSINS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2733 FOREST RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30222-2260
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1610 10TH ST
Practice Address - Street 2:CLARK-HOLDER CLINIC, P.A.
Practice Address - City:WEST POINT
Practice Address - State:GA
Practice Address - Zip Code:31833
Practice Address - Country:US
Practice Address - Phone:706-645-2300
Practice Address - Fax:706-645-2312
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN106393363LF0000X
AL1-067853363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily