Healthcare Provider Details

I. General information

NPI: 1881860716
Provider Name (Legal Business Name): DIANE AVERY HANCOCK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 BROAD ROCK BLVD
RICHMOND VA
23249
US

IV. Provider business mailing address

1201 BROAD ROCK BLVD
RICHMOND VA
23249
US

V. Phone/Fax

Practice location:
  • Phone: 804-675-5553
  • Fax: 804-675-5778
Mailing address:
  • Phone: 804-675-5553
  • Fax: 804-675-5778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number5003970
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0024169724
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: