Provider Demographics
NPI:1245567429
Name:DIEHL, MICHELLE-ANNE (PSYD, RN)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE-ANNE
Middle Name:
Last Name:DIEHL
Suffix:
Gender:F
Credentials:PSYD, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 LITHIA PINECREST RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5307
Mailing Address - Country:US
Mailing Address - Phone:813-957-2765
Mailing Address - Fax:813-502-6144
Practice Address - Street 1:209 LITHIA PINECREST RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5307
Practice Address - Country:US
Practice Address - Phone:813-957-2765
Practice Address - Fax:813-502-6144
Is Sole Proprietor?:No
Enumeration Date:2009-11-10
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8005103TC0700X
FL9197701163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEA676ZMedicare UPIN