Healthcare Provider Details

I. General information

NPI: 1043679079
Provider Name (Legal Business Name): DIANNA FORREST DOUGLASS PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 HIGHWAY 7 S
OXFORD MS
38655-5392
US

IV. Provider business mailing address

58 COUNTY ROAD 373
WATER VALLEY MS
38965-3740
US

V. Phone/Fax

Practice location:
  • Phone: 662-234-7521
  • Fax: 662-236-3071
Mailing address:
  • Phone: 662-202-4705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number901761
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number903689
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: