Healthcare Provider Details

I. General information

NPI: 1407347214
Provider Name (Legal Business Name): DIANA RUDNEV MSN, RN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 JOHN R ST
DETROIT MI
48201-2013
US

IV. Provider business mailing address

4100 JOHN R ST
DETROIT MI
48201-2013
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-9092
  • Fax: 313-576-8486
Mailing address:
  • Phone: 313-576-9092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704262778
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704262778
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: