Provider Demographics
NPI:1790880045
Name:PELLETIER, DIANE PEARL (CNM)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:PEARL
Last Name:PELLETIER
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 1:5480 PRENTISS LN
Mailing Address - Street 2:
Mailing Address - City:IRON STATION
Mailing Address - State:NC
Mailing Address - Zip Code:28080-9267
Mailing Address - Country:US
Mailing Address - Phone:704-735-4823
Mailing Address - Fax:
Practice Address - Street 1:991 W HUDSON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-6430
Practice Address - Country:US
Practice Address - Phone:704-853-5260
Practice Address - Fax:704-853-5252
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCNM 103367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife