Provider Demographics
NPI:1467179226
Name:VAN DYKE, MARIAH MARIANNE (LM, CPM)
Entity Type:Individual
Prefix:MRS
First Name:MARIAH
Middle Name:MARIANNE
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2134 VICTOR AVE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-0407
Mailing Address - Country:US
Mailing Address - Phone:530-722-7569
Mailing Address - Fax:
Practice Address - Street 1:1727 SOUTH ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1812
Practice Address - Country:US
Practice Address - Phone:530-722-7569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALM691176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CPM22080027OtherNARM
CALM691OtherMEDICAL BOARD OF CALIFORNIA