Basic Information
| Provider Information | |||||||||
| NPI: | 1295962504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 COUNTY ROAD 917 | ||||||||
| Address2: | |||||||||
| City: | BROOKLAND | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724178873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702534349 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 CARSON ST | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724013104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709321198 | ||||||||
| FaxNumber: | 8709107710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2009 | ||||||||
| LastUpdateDate: | 02/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R81466 | AR | N | Nursing Service Providers | Registered Nurse | 363LF0000X | A004096 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.