Healthcare Provider Details

I. General information

NPI: 1053695395
Provider Name (Legal Business Name): DIANA NEMIROVSKY CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 ASHBY AVE RM 3040
BERKELEY CA
94705-2067
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 510-204-3977
  • Fax: 510-204-5429
Mailing address:
  • Phone: 510-204-3977
  • Fax: 510-204-5429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number753612
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number21112
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number1963
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: