Basic Information
| Provider Information | |||||||||
| NPI: | 1578632808 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPIVA | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1557 JANMAR RD | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300785686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783448900 | ||||||||
| FaxNumber: | 6786665201 | ||||||||
| Practice Location | |||||||||
| Address1: | 10730 MEDLOCK BRIDGE RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | JOHNS CREEK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300972638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783448900 | ||||||||
| FaxNumber: | 6786665201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
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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 | 363LA2200X | 1-117580 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | 1-117580 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LW0102X | 1-117580 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 367500000X | 55532 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 363LF0000X | RN278076 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | RN278076 | 01 | GA | RN LICENSE | OTHER | RN278076 | 01 | GA | APRN LICENSE | OTHER | 1-117580 | 01 | AL | RN LICENSE | OTHER | 55532 | 01 | KS | RNA LICENSE | OTHER | 1-117580 | 01 | AL | CRNP LICENSE | OTHER | 1391784012 | 01 | KS | RN LICENSE | OTHER |