Provider Demographics
NPI:1487365599
Name:FORT, DIANNA ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:DIANNA
Middle Name:ELIZABETH
Last Name:FORT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-3027
Mailing Address - Country:US
Mailing Address - Phone:318-294-6337
Mailing Address - Fax:
Practice Address - Street 1:246 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-3027
Practice Address - Country:US
Practice Address - Phone:318-294-6337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN158038163WH1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH1000XNursing Service ProvidersRegistered NurseHospiceGroup - Single Specialty