Provider Demographics
NPI:1790444917
Name:DIENER, LEE A
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:A
Last Name:DIENER
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 1:15146 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:MARNE
Mailing Address - State:MI
Mailing Address - Zip Code:49435-9605
Mailing Address - Country:US
Mailing Address - Phone:844-776-9651
Mailing Address - Fax:
Practice Address - Street 1:15146 16TH AVE
Practice Address - Street 2:
Practice Address - City:MARNE
Practice Address - State:MI
Practice Address - Zip Code:49435-9605
Practice Address - Country:US
Practice Address - Phone:844-776-9651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-15
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704320707363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health