Provider Demographics
NPI:1508940206
Name:KLINGLER, DIANE KAY (RN, ANP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:KAY
Last Name:KLINGLER
Suffix:
Gender:F
Credentials:RN, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6777 W MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3013
Mailing Address - Country:US
Mailing Address - Phone:313-575-6315
Mailing Address - Fax:248-661-6468
Practice Address - Street 1:6777 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3013
Practice Address - Country:US
Practice Address - Phone:248-661-6461
Practice Address - Fax:248-661-6468
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704185793363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI108888888Medicaid
MI108888888Medicaid
MIP20308Medicare UPIN