Basic Information
| Provider Information | |||||||||
| NPI: | 1043679079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLASS | ||||||||
| FirstName: | DIANNA | ||||||||
| MiddleName: | FORREST | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 58 COUNTY ROAD 373 | ||||||||
| Address2: | |||||||||
| City: | WATER VALLEY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389653740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622024705 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 152 HIGHWAY 7 S | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386555392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622347521 | ||||||||
| FaxNumber: | 6622363071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2016 | ||||||||
| LastUpdateDate: | 07/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 901761 | MS | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | 903689 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.