Provider Demographics
NPI:1215434063
Name:LOFTON, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:LOFTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3956 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ECORSE
Mailing Address - State:MI
Mailing Address - Zip Code:48229-1310
Mailing Address - Country:US
Mailing Address - Phone:313-983-9212
Mailing Address - Fax:
Practice Address - Street 1:3956 17TH ST
Practice Address - Street 2:
Practice Address - City:ECORSE
Practice Address - State:MI
Practice Address - Zip Code:48229-1310
Practice Address - Country:US
Practice Address - Phone:313-983-9212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703100641164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse