Healthcare Provider Details

I. General information

NPI: 1184801961
Provider Name (Legal Business Name): DIANA LEE NASH LM, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2008
Last Update Date: 04/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 VENUS DR
LESLIE AR
72645-7110
US

IV. Provider business mailing address

106 VENUS DR
LESLIE AR
72645-7110
US

V. Phone/Fax

Practice location:
  • Phone: 870-221-1080
  • Fax:
Mailing address:
  • Phone: 870-221-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number022012
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number99270
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: