Provider Demographics
NPI:1548283062
Name:ANDERSON, DIANE (NP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1676 VIEWPOND DR SE
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-4994
Mailing Address - Country:US
Mailing Address - Phone:616-455-9450
Mailing Address - Fax:616-455-9450
Practice Address - Street 1:1676 VIEWPOND DR SE
Practice Address - Street 2:SUITE 100A
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-4994
Practice Address - Country:US
Practice Address - Phone:616-455-9450
Practice Address - Fax:616-455-5221
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704101913363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4849371Medicaid
1598853608OtherGROUP NPI - JOHN N CAMPBELL MD PC
0P28470Medicare PIN