MEDICARE: MRS. MACEY DIANA ELKS NP

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	363LG0600X	Gerontology Nurse Practitioner	NP224167	GA
2	363L00000X	Nurse Practitioner	RN224167	GA
3	363LA2100X	Acute Care Nurse Practitioner	RN224167	GA

General Provider Information

NPI Number	:	1356854202
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MACEY DIANA ELKS NP

Provider Business Mailing Address
First Line	:	3051 WATSON BLVD STE 525
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31093-8556
Country	:	US
Telephone Number	:	478-953-4563
Fax Number	:	478-953-4564

Provider Business Practice Location Address
First Line	:	3051 WATSON BLVD STE 525
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31093
Country	:	US
Telephone Number	:	478-953-4563
Fax Number	:	478-953-4564

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2017
Last Update Date	:	03/05/2026

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