Provider Demographics
NPI:1154354884
Name:TANDY, DIANE S (CNM)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:S
Last Name:TANDY
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 SIMS ST
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3851
Mailing Address - Country:US
Mailing Address - Phone:770-536-0149
Mailing Address - Fax:770-536-0317
Practice Address - Street 1:1285 SIMS ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3851
Practice Address - Country:US
Practice Address - Phone:770-536-0149
Practice Address - Fax:770-536-0317
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN093246367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I422022OtherMEDICARE - GEORGIA
GA5002152OtherAETNA
GA000651868KMedicaid
GA000651868FMedicaid
GA000651868D OR FOtherPEACHSTATE
GA332884OtherWELLCARE
GA000651868CMedicaid
GA000651868DMedicaid