Basic Information
| Provider Information | |||||||||
| NPI: | 1760419212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEID | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 446 | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481060446 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 128 VAN BUREN ST | ||||||||
| Address2: | |||||||||
| City: | CHELSEA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481181623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344758677 | ||||||||
| FaxNumber: | 7343270826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 01/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 143379 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | DW143379 | 01 | MI | BLUE SHIELD | OTHER | 104425850 | 05 | MI | MEDICAID |