Healthcare Provider Details

I. General information

NPI: 1952073108
Provider Name (Legal Business Name): MAVIS DIGGS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 2ND AVE STE 266
DETROIT MI
48201-2675
US

IV. Provider business mailing address

2727 2ND AVE STE 266
DETROIT MI
48201-2675
US

V. Phone/Fax

Practice location:
  • Phone: 313-451-0405
  • Fax:
Mailing address:
  • Phone: 313-451-0405
  • Fax: 586-999-8836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704347831
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: