Provider Demographics
NPI:1295991057
Name:MORRIS, DIANE (CFNP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MORRIS
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13445
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-3445
Mailing Address - Country:US
Mailing Address - Phone:601-832-2450
Mailing Address - Fax:
Practice Address - Street 1:910 SECOND ST
Practice Address - Street 2:
Practice Address - City:PRENTISS
Practice Address - State:MS
Practice Address - Zip Code:39474-9117
Practice Address - Country:US
Practice Address - Phone:601-792-2078
Practice Address - Fax:601-792-8211
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR652067363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00457841Medicaid