Provider Demographics
NPI:1740806470
Name:KIM, DIANE (CNM)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:KIM
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 1:1650 GRAND CONCOURSE
Mailing Address - Street 2:FL 5
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457
Mailing Address - Country:US
Mailing Address - Phone:714-518-5290
Mailing Address - Fax:
Practice Address - Street 1:1650 GRAND CONCOURSE
Practice Address - Street 2:FL 5
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457
Practice Address - Country:US
Practice Address - Phone:714-518-5290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
176B00000X
NY002014207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No176B00000XOther Service ProvidersMidwife