Provider Demographics
NPI:1164833653
Name:WILSON, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:WILSON
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 1:6551 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-1125
Mailing Address - Country:US
Mailing Address - Phone:313-656-4494
Mailing Address - Fax:313-656-4494
Practice Address - Street 1:6551 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-1125
Practice Address - Country:US
Practice Address - Phone:313-656-4494
Practice Address - Fax:313-656-4494
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMDOT-71649343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)