Provider Demographics
NPI:1154358505
Name:TRAENKLE, DIANE RENEE (DO)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:RENEE
Last Name:TRAENKLE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 E BROOMFIELD ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-5427
Mailing Address - Country:US
Mailing Address - Phone:989-772-3009
Mailing Address - Fax:989-772-0568
Practice Address - Street 1:1621 E BROOMFIELD ST
Practice Address - Street 2:SUITE B
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-5427
Practice Address - Country:US
Practice Address - Phone:989-772-3009
Practice Address - Fax:989-772-9301
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011733207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4824793-11Medicaid
MI1017077OtherMCLAREN HEALTH PLAN
MI0953701185OtherBCBSM
MIP25680001Medicare PIN
MI4824793-11Medicaid