Healthcare Provider Details

I. General information

NPI: 1053604058
Provider Name (Legal Business Name): DIANA VALLARTA KOROI LM, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DIANA RENEE VALLARTA

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

967 W. HEDDING ST STE 110
SAN JOSE CA
95126
US

IV. Provider business mailing address

PO BOX 2179
LOS GATOS CA
95031
US

V. Phone/Fax

Practice location:
  • Phone: 408-886-4961
  • Fax: 408-412-5020
Mailing address:
  • Phone: 408-886-4961
  • Fax: 408-412-5020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM303
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: