Provider Demographics
NPI:1356324552
Name:DIEDO, NOREEN KAY (NP)
Entity type:Individual
Prefix:MRS
First Name:NOREEN
Middle Name:KAY
Last Name:DIEDO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:4885 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2324
Mailing Address - Country:US
Mailing Address - Phone:586-751-1535
Mailing Address - Fax:586-751-1535
Practice Address - Street 1:11800 E 12 MILE RD
Practice Address - Street 2:ST JOHN MACOMB
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093
Practice Address - Country:US
Practice Address - Phone:586-576-4063
Practice Address - Fax:586-573-5802
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704122516363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704122516Medicaid
MI4704122516Medicaid
P54788Medicare UPIN