Provider Demographics
NPI:1487317582
Name:DIETZ ALESSI, LAUREN (PA)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:DIETZ ALESSI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 N OLD WOODWARD AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-5412
Mailing Address - Country:US
Mailing Address - Phone:248-505-7232
Mailing Address - Fax:
Practice Address - Street 1:42757 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-5037
Practice Address - Country:US
Practice Address - Phone:248-640-4751
Practice Address - Fax:248-940-4750
Is Sole Proprietor?:No
Enumeration Date:2021-10-16
Last Update Date:2025-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011405363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant