Provider Demographics
NPI:1710589429
Name:MANSOUR, DIANE AMIR (AGNP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:AMIR
Last Name:MANSOUR
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6180 CHESHIRE PARK DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4815
Mailing Address - Country:US
Mailing Address - Phone:248-505-2813
Mailing Address - Fax:
Practice Address - Street 1:5220 HIGHLAND RD STE 240
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1973
Practice Address - Country:US
Practice Address - Phone:248-237-6580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704304113363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health