Provider Demographics
NPI:1003806688
Name:JUNIOR, DIANNE (NP)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:
Last Name:JUNIOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 WYNDEMERE SQ
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-8891
Mailing Address - Country:US
Mailing Address - Phone:810-655-5103
Mailing Address - Fax:
Practice Address - Street 1:G3525 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-1260
Practice Address - Country:US
Practice Address - Phone:810-222-3040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704195342363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner