Healthcare Provider Details

I. General information

NPI: 1679565485
Provider Name (Legal Business Name): MARIBETH DIVER CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E LEXINGTON AVE
PHOENIX AZ
85012-2321
US

IV. Provider business mailing address

215 E LEXINGTON AVE
PHOENIX AZ
85012-2321
US

V. Phone/Fax

Practice location:
  • Phone: 602-314-7755
  • Fax: 602-314-7756
Mailing address:
  • Phone: 602-314-7755
  • Fax: 602-314-7756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMW010045
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP1723
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: