Provider Demographics
NPI:1184786717
Name:CARLISLE, DIANE CAMPBELL (RNC)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:CAMPBELL
Last Name:CARLISLE
Suffix:
Gender:F
Credentials:RNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:476 GOLDFINCH DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-8102
Mailing Address - Country:US
Mailing Address - Phone:662-335-1728
Mailing Address - Fax:
Practice Address - Street 1:1633 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3222
Practice Address - Country:US
Practice Address - Phone:662-332-8177
Practice Address - Fax:662-378-8853
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR588911363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123989Medicaid
MS500001413Medicare ID - Type UnspecifiedDIANE CARLISLE
MS00123989Medicaid