Healthcare Provider Details

I. General information

NPI: 1821500018
Provider Name (Legal Business Name): DIANA LYNN VARDEMAN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2017
Last Update Date: 12/29/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 11TH ST
WICHITA FALLS TX
76301-4300
US

IV. Provider business mailing address

15347 FM 1954
WICHITA FALLS TX
76310-0370
US

V. Phone/Fax

Practice location:
  • Phone: 940-764-4248
  • Fax: 940-764-4249
Mailing address:
  • Phone: 940-636-9482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP135260
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: