Provider Demographics
NPI:1932115813
Name:PETERSON, DIANA L (CNM)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:PETERSON
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 1:1151 E 3900 S
Mailing Address - Street 2:SUITE B-299
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1216
Mailing Address - Country:US
Mailing Address - Phone:801-268-6811
Mailing Address - Fax:801-268-8673
Practice Address - Street 1:1151 E 3900 S
Practice Address - Street 2:SUITE B-299
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1216
Practice Address - Country:US
Practice Address - Phone:801-268-6811
Practice Address - Fax:801-268-8673
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT209334-4402176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS59881Medicare UPIN