Provider Demographics
NPI:1437562840
Name:NCHAMUKONG, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:NCHAMUKONG
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 1:27034 SPRUCEWOOD DR APT 102
Mailing Address - Street 2:
Mailing Address - City:WIXOM
Mailing Address - State:MI
Mailing Address - Zip Code:48393
Mailing Address - Country:US
Mailing Address - Phone:248-790-5926
Mailing Address - Fax:
Practice Address - Street 1:27034 SPRUCEWOOD DR APT 102
Practice Address - Street 2:
Practice Address - City:WIXOM
Practice Address - State:MI
Practice Address - Zip Code:48393-3275
Practice Address - Country:US
Practice Address - Phone:248-790-5926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703106356164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse