Provider Demographics
NPI:1689017915
Name:PHILLIPS, DIANNA (RN)
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:DIANNA
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:1040 RIVER OAKS DR
Mailing Address - Street 2:SUITE 302
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9530
Mailing Address - Country:US
Mailing Address - Phone:601-939-9723
Mailing Address - Fax:601-939-9924
Practice Address - Street 1:1040 RIVER OAKS DR
Practice Address - Street 2:SUITE 302
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39232-9530
Practice Address - Country:US
Practice Address - Phone:601-939-9723
Practice Address - Fax:601-939-9924
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR724777163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse