Provider Demographics
NPI:1588097687
Name:DUVALL, DIJANA (APRN)
Entity type:Individual
Prefix:MRS
First Name:DIJANA
Middle Name:
Last Name:DUVALL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:DIJANA
Other - Middle Name:
Other - Last Name:MANOJLOVIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:280 PASADENA DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2925
Mailing Address - Country:US
Mailing Address - Phone:859-278-1316
Mailing Address - Fax:859-276-3847
Practice Address - Street 1:2416 REGENCY RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2954
Practice Address - Country:US
Practice Address - Phone:859-278-1316
Practice Address - Fax:859-276-3847
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008192363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100274880Medicaid