Healthcare Provider Details

I. General information

NPI: 1598469066
Provider Name (Legal Business Name): DIANA MIMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 07/11/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 BROWNING ROAD 520
GREENWOOD MS
38930-6022
US

IV. Provider business mailing address

2504 BROWNING ROAD 520
GREENWOOD MS
38930-6022
US

V. Phone/Fax

Practice location:
  • Phone: 662-453-6211
  • Fax:
Mailing address:
  • Phone: 662-453-6211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR890200
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number906015
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: