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General NPI Number Information
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NPI Number | 1437442803
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Entity Type | Individual
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Provider Name | DIANE BOULAI LPN
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Gender | Female
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Dates
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Enumeration Date | 05/18/2011
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Last Update Date | 02/12/2024
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Provider Practice Location Address
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Address Line | 6944 HIGHWAY 85 STE F
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City | RIVERDALE
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State | GA
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Zip | 30274-2960
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Country | US
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Telephone | 770-683-6946
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Fax | 770-683-6949
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Provider Business Mailing Address
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Address Line | 361 CLIFFHAVEN CIR
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City | NEWNAN
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State | GA
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Zip | 30263-6358
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Country | US
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Telephone | 678-477-3476
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Fax | 770-683-6946
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | LPN061853
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License Number State | GA
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