Provider Demographics
NPI:1497077051
Name:CORCORAN, DIANE ELANE
Entity Type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:ELANE
Last Name:CORCORAN
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 1:9288 SEYMOUR RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:MI
Mailing Address - Zip Code:48457-9122
Mailing Address - Country:US
Mailing Address - Phone:810-639-2222
Mailing Address - Fax:810-639-2233
Practice Address - Street 1:9288 SEYMOUR RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:MI
Practice Address - Zip Code:48457-9122
Practice Address - Country:US
Practice Address - Phone:810-639-2222
Practice Address - Fax:810-639-2233
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2101054404171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications