Provider Demographics
NPI:1386990463
Name:WADSWORTH, DIANNA WALLER (FNP)
Entity type:Individual
Prefix:
First Name:DIANNA
Middle Name:WALLER
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DIANNA
Other - Middle Name:MARY
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1375 CORPORATE SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-3147
Mailing Address - Country:US
Mailing Address - Phone:985-649-1152
Mailing Address - Fax:985-643-9808
Practice Address - Street 1:1051 GAUSE BLVD
Practice Address - Street 2:SUITE 380
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2951
Practice Address - Country:US
Practice Address - Phone:985-641-8191
Practice Address - Fax:985-641-9812
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06883364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health