Provider Demographics
NPI:1750387890
Name:DAVIS, DIANE L (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 W QUITMAN ST
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-1132
Mailing Address - Country:US
Mailing Address - Phone:662-423-1000
Mailing Address - Fax:662-423-1316
Practice Address - Street 1:1507 W QUITMAN ST
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1132
Practice Address - Country:US
Practice Address - Phone:662-423-1000
Practice Address - Fax:662-423-1316
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR866519363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03171239Medicaid
MS03171239Medicaid