Healthcare Provider Details

I. General information

NPI: 1356167209
Provider Name (Legal Business Name): MEENA KUMARI DIETERICH CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 NORTH AVE APT 1
BURLINGTON VT
05401-2909
US

IV. Provider business mailing address

89 N CHAMPLAIN ST APT B
BURLINGTON VT
05401-4319
US

V. Phone/Fax

Practice location:
  • Phone: 917-912-0516
  • Fax:
Mailing address:
  • Phone: 917-912-0516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number107.0129930
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: