Healthcare Provider Details

I. General information

NPI: 1255336327
Provider Name (Legal Business Name): JOANNE RUTH DIETZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 W 9 MILE RD
SOUTHFIELD MI
48075-4818
US

IV. Provider business mailing address

25925 TELEGRAPH RD STE 210
SOUTHFIELD MI
48034-2527
US

V. Phone/Fax

Practice location:
  • Phone: 248-746-3218
  • Fax: 248-746-0369
Mailing address:
  • Phone: 248-746-0342
  • Fax: 248-746-0308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number4704069138
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: