1154354884 NPI number — DIANE S TANDY CNM

Table of content: DIANE S TANDY CNM (NPI 1154354884)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154354884 NPI number — DIANE S TANDY CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TANDY
Provider First Name:
DIANE
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154354884
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1285 SIMS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30501-3851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-536-0149
Provider Business Mailing Address Fax Number:
770-536-0317

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1285 SIMS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501-3851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-536-0149
Provider Business Practice Location Address Fax Number:
770-536-0317
Provider Enumeration Date:
07/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367A00000X , with the licence number:  RN093246 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 202I422022 . This is a "MEDICARE - GEORGIA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 5002152 . This is a "AETNA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000651868K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000651868F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000651868D OR F . This is a "PEACHSTATE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 332884 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000651868C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000651868D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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