Healthcare Provider Details

I. General information

NPI: 1033405600
Provider Name (Legal Business Name): DIANA GRAY MILLENBAUGH MSN, RNP, BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 06/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 CAMDEN RD STE 12
PINE BLUFF AR
71603-4612
US

IV. Provider business mailing address

3801 CAMDEN RD STE 12
PINE BLUFF AR
71603-4612
US

V. Phone/Fax

Practice location:
  • Phone: 870-534-4847
  • Fax: 870-534-4884
Mailing address:
  • Phone: 870-534-4847
  • Fax: 870-534-4884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA02944ANP
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: