Basic Information
| Provider Information | |||||||||
| NPI: | 1831185313 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LITTLE | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | CAMPBELL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3686 US HIGHWAY 331 S | ||||||||
| Address2: | |||||||||
| City: | DEFUNIAK SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324358463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508928045 | ||||||||
| FaxNumber: | 8508928039 | ||||||||
| Practice Location | |||||||||
| Address1: | 3686 US HIGHWAY 331 S | ||||||||
| Address2: | |||||||||
| City: | DEFUNIAK SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324358463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508928045 | ||||||||
| FaxNumber: | 8508928039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 09/01/2011 | ||||||||
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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 | ARNPRN839422 | FL | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | Y9808 | 01 | FL | BCBS | OTHER | 761912000 | 05 | FL | MEDICAID |