Basic Information
| Provider Information | |||||||||
| NPI: | 1407376254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIMINO | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | MCTAGGART | ||||||||
| NamePrefix: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MCTAGGART | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | ROSE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209446 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 255 BAPTIST BLVD STE 301 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397052006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622442550 | ||||||||
| FaxNumber: | 6622442553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 901954 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.