Provider Demographics
NPI:1720465248
Name:MOSS, DIANE (RRT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MOSS
Suffix:
Gender:F
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 JEFFERSON AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4306
Mailing Address - Country:US
Mailing Address - Phone:616-685-1433
Mailing Address - Fax:616-685-1437
Practice Address - Street 1:150 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4306
Practice Address - Country:US
Practice Address - Phone:616-685-1433
Practice Address - Fax:616-685-1437
Is Sole Proprietor?:No
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI44010018782279E1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2279E1000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredEducational