Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | A456 | SC |
N | 363LA2200X | Nurse Practitioner - Adult Health | A456 | SC |
NPI | 1003841578 |
---|---|
Provider Name | Mrs. Diane Marie Jenner |
First Address | Columbia, SC 29209-1639 |
Second Address | Columbia, SC 29209-1639 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2006 |
Last Update Date | 01/09/2016 |