Provider Demographics
NPI:1316584865
Name:WHITE, DIANE SUSAN (NP-C)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:SUSAN
Last Name:WHITE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 POLIFKA DR BLDG 1042
Mailing Address - Street 2:
Mailing Address - City:SHAW AFB
Mailing Address - State:SC
Mailing Address - Zip Code:29152-5100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 POLIFKA DR BLDG 1042
Practice Address - Street 2:
Practice Address - City:SHAW AFB
Practice Address - State:SC
Practice Address - Zip Code:29152-5100
Practice Address - Country:US
Practice Address - Phone:803-895-6356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23495363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily