Healthcare Provider Details

I. General information

NPI: 1417147844
Provider Name (Legal Business Name): DIANE MUDGE PARKS M.S.N.,W.H.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19825 N COVE RD STE B
CORNELIUS NC
28031-0149
US

IV. Provider business mailing address

19825 N COVE RD STE B
CORNELIUS NC
28031-0149
US

V. Phone/Fax

Practice location:
  • Phone: 704-799-5433
  • Fax: 704-706-2446
Mailing address:
  • Phone: 704-799-5433
  • Fax: 704-706-2446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number940100
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number940100
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number110557
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: