Healthcare Provider Details

I. General information

NPI: 1386990463
Provider Name (Legal Business Name): DIANNA WALLER WADSWORTH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANNA MARY WALLER

II. Dates (important events)

Enumeration Date: 07/26/2012
Last Update Date: 07/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 GAUSE BLVD SUITE 380
SLIDELL LA
70458-2951
US

IV. Provider business mailing address

1375 CORPORATE SQUARE DR
SLIDELL LA
70458-3147
US

V. Phone/Fax

Practice location:
  • Phone: 985-641-8191
  • Fax: 985-641-9812
Mailing address:
  • Phone: 985-649-1152
  • Fax: 985-643-9808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberAP06883
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: