Healthcare Provider Details

I. General information

NPI: 1639073166
Provider Name (Legal Business Name): DIAMOND GENTRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 E WEST MAPLE RD STE 200
WALLED LAKE MI
48390-3571
US

IV. Provider business mailing address

1010 E WEST MAPLE RD STE 200
WALLED LAKE MI
48390-3571
US

V. Phone/Fax

Practice location:
  • Phone: 734-498-0594
  • Fax:
Mailing address:
  • Phone: 734-498-0594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703129667
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: