Provider Demographics
NPI:1093781858
Name:RICHARDSON, DIANE K (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:K
Last Name:RICHARDSON
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:PO BOX 1767
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1767
Mailing Address - Country:US
Mailing Address - Phone:616-235-2090
Mailing Address - Fax:616-235-2099
Practice Address - Street 1:141 PORT SHELDON RD SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2149
Practice Address - Country:US
Practice Address - Phone:616-235-2090
Practice Address - Fax:616-235-2099
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704110245363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P208300001Medicare ID - Type Unspecified