Healthcare Provider Details

I. General information

NPI: 1164916243
Provider Name (Legal Business Name): DIANNE FOX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 RAYBROOK ST SE
GRAND RAPIDS MI
49546-7759
US

IV. Provider business mailing address

1786 LILAC CT
JENISON MI
49428-8519
US

V. Phone/Fax

Practice location:
  • Phone: 919-956-9440
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704092609
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: