Provider Demographics
NPI:1407612823
Name:GUM, DIANE RENEE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:RENEE
Last Name:GUM
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 1:1111 CATHERINE ST LOT 65
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-1169
Mailing Address - Country:US
Mailing Address - Phone:231-349-2089
Mailing Address - Fax:
Practice Address - Street 1:1111 CATHERINE ST LOT 65
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-1169
Practice Address - Country:US
Practice Address - Phone:231-349-2089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI9334448374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide