Provider Demographics
NPI:1235685041
Name:REGO, DIANA (NP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:REGO
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 1:24 FRANK LLOYD WRIGHT DR. LOBBY J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5325 ELLIOTT DR
Practice Address - Street 2:SUITE 104
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8633
Practice Address - Country:US
Practice Address - Phone:734-712-8150
Practice Address - Fax:734-712-8151
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704287193363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner