Provider Demographics
NPI:1770530347
Name:BROCKMAN, DIANA LYNN (FNP)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:RIDDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:257 BANCORP SOUTH PKWY
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-7582
Mailing Address - Country:US
Mailing Address - Phone:731-660-8781
Mailing Address - Fax:
Practice Address - Street 1:238 SUMMAR DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3906
Practice Address - Country:US
Practice Address - Phone:731-935-8200
Practice Address - Fax:731-935-8327
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN59629363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health