Provider Demographics
NPI:1831131978
Name:STOLLER, DIANE (CRNA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:STOLLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 SANDRA CT
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-4137
Mailing Address - Country:US
Mailing Address - Phone:313-274-5061
Mailing Address - Fax:248-357-0915
Practice Address - Street 1:707 SANDRA CT
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-4137
Practice Address - Country:US
Practice Address - Phone:313-274-5061
Practice Address - Fax:248-357-0915
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704091295367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDS091295OtherBCBSM NUMBER