Provider Demographics
NPI:1467150763
Name:TRALONGO, DIANE FRANCES (PA)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:FRANCES
Last Name:TRALONGO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:DIANE
Other - Middle Name:FRANCES
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3523 GRANGE HALL RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-1007
Mailing Address - Country:US
Mailing Address - Phone:248-382-5791
Mailing Address - Fax:
Practice Address - Street 1:3523 GRANGE HALL RD
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-1007
Practice Address - Country:US
Practice Address - Phone:248-382-5791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002470363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical