Healthcare Provider Details

I. General information

NPI: 1871992917
Provider Name (Legal Business Name): DIANA BATES REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N WEST AVE SUITE 300
JACKSON MI
49202-2179
US

IV. Provider business mailing address

1200 N WEST AVE SUITE 300
JACKSON MI
49202-2179
US

V. Phone/Fax

Practice location:
  • Phone: 517-789-1234
  • Fax: 517-784-7840
Mailing address:
  • Phone: 517-789-1234
  • Fax: 517-784-7840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704167960
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: