Provider Demographics
NPI:1134585037
Name:MATTHEWSMATTHEWS01, DIANE
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:MATTHEWSMATTHEWS01
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 1:113 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:RIVER ROUGE
Mailing Address - State:MI
Mailing Address - Zip Code:48218-1545
Mailing Address - Country:US
Mailing Address - Phone:313-286-9213
Mailing Address - Fax:
Practice Address - Street 1:113 WALNUT ST
Practice Address - Street 2:
Practice Address - City:RIVER ROUGE
Practice Address - State:MI
Practice Address - Zip Code:48218-1545
Practice Address - Country:US
Practice Address - Phone:313-286-9213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703101181251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care