Healthcare Provider Details

I. General information

NPI: 1891886024
Provider Name (Legal Business Name): DIANE M PRIVITOR DAVIS FNP-C, PMHNPBC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 STUBBS AVE
MONROE LA
71201-7120
US

IV. Provider business mailing address

200 WINTERPARK DR
WEST MONROE LA
71292-1106
US

V. Phone/Fax

Practice location:
  • Phone: 318-816-5116
  • Fax: 318-855-3429
Mailing address:
  • Phone: 318-509-8008
  • Fax: 318-329-1258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP05002
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPO5002
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: