Healthcare Provider Details

I. General information

NPI: 1154225522
Provider Name (Legal Business Name): ASHLEY DIANA TAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7483
US

IV. Provider business mailing address

1914 JUMPIN RUN DR
WILMINGTON NC
28403-5335
US

V. Phone/Fax

Practice location:
  • Phone: 910-662-9290
  • Fax:
Mailing address:
  • Phone: 910-471-0624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5025653
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: