Provider Demographics
NPI:1659635951
Name:SHEPARDSON, DIA (CM, LM)
Entity Type:Individual
Prefix:
First Name:DIA
Middle Name:
Last Name:SHEPARDSON
Suffix:
Gender:F
Credentials:CM, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 E BROADWAY APT A507
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-5653
Mailing Address - Country:US
Mailing Address - Phone:917-817-8873
Mailing Address - Fax:
Practice Address - Street 1:268 E BROADWAY APT A507
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-5653
Practice Address - Country:US
Practice Address - Phone:917-817-8873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY374J00000X
NYF001749-1367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No374J00000XNursing Service Related ProvidersDoula