Healthcare Provider Details

I. General information

NPI: 1578632808
Provider Name (Legal Business Name): DIANE L SPIVA CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10730 MEDLOCK BRIDGE RD STE 110
JOHNS CREEK GA
30097-2638
US

IV. Provider business mailing address

1557 JANMAR RD
SNELLVILLE GA
30078-5686
US

V. Phone/Fax

Practice location:
  • Phone: 678-344-8900
  • Fax: 678-666-5201
Mailing address:
  • Phone: 678-344-8900
  • Fax: 678-666-5201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1-117580
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-117580
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number1-117580
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number55532
License Number StateKS
# 5
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN278076
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: