MEDICARE: DIVERSIFIED NURSING SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R826442	MS

General Provider Information

NPI Number	:	1215002498
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSIFIED NURSING SERVICES, INC.

Provider Business Mailing Address
First Line	:	770 N WOLFE RD
Second Line	:
City	:	CALEDONIA
State	:	MS
Zip	:	39740-9763
Country	:	US
Telephone Number	:	662-251-4055
Fax Number	:	662-304-4002

Provider Business Practice Location Address
First Line	:	505 JACKSON ST
Second Line	:
City	:	ABERDEEN
State	:	MS
Zip	:	39730-3349
Country	:	US
Telephone Number	:	662-369-6431
Fax Number	:	662-369-6473

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. LISA B COOPER
Credential	:	CFNP
Telephone Number	:	662-251-4055

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	08/22/2020

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