Healthcare Provider Details

I. General information

NPI: 1861571820
Provider Name (Legal Business Name): DIANE P. ROUSSEAU C.N.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8015 W ALAMEDA AVE STE 20
LAKEWOOD CO
80226-3075
US

IV. Provider business mailing address

8015 W ALAMEDA AVE STE 20
LAKEWOOD CO
80226-3075
US

V. Phone/Fax

Practice location:
  • Phone: 303-935-6705
  • Fax: 303-935-6769
Mailing address:
  • Phone: 303-935-6705
  • Fax: 303-935-6769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number55130
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: