Provider Demographics
NPI:1861400426
Name:FORD, DIANE MARIE (APRN)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:MARIE
Last Name:FORD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8665 GEORGE AVE
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1409
Mailing Address - Country:US
Mailing Address - Phone:269-471-4902
Mailing Address - Fax:
Practice Address - Street 1:1045 E FRONT ST
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-8474
Practice Address - Country:US
Practice Address - Phone:269-695-5540
Practice Address - Fax:269-695-0412
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI28138958A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4511986Medicaid
MIQ67362Medicare UPIN
MI0P30260Medicare ID - Type Unspecified