Healthcare Provider Details

I. General information

NPI: 1659635951
Provider Name (Legal Business Name): DIA SHEPARDSON CM, LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 E BROADWAY APT A507
NEW YORK NY
10002-5653
US

IV. Provider business mailing address

268 E BROADWAY APT A507
NEW YORK NY
10002-5653
US

V. Phone/Fax

Practice location:
  • Phone: 917-817-8873
  • Fax:
Mailing address:
  • Phone: 917-817-8873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberF001749-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: