Provider Demographics
NPI:1114525789
Name:DIBLE, GRACE PATRICIA (CNM)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:PATRICIA
Last Name:DIBLE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1229 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-1932
Mailing Address - Country:US
Mailing Address - Phone:312-479-2252
Mailing Address - Fax:
Practice Address - Street 1:951 MARINERS ISLAND BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94404-1560
Practice Address - Country:US
Practice Address - Phone:650-285-6927
Practice Address - Fax:888-352-7383
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000360A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife