Provider Demographics
NPI:1457358095
Name:NICHOLSON, DIANE A (CNM)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:A
Last Name:NICHOLSON
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 1:5925 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-5009
Mailing Address - Country:US
Mailing Address - Phone:718-972-2700
Mailing Address - Fax:718-532-1724
Practice Address - Street 1:5925 15TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-5009
Practice Address - Country:US
Practice Address - Phone:718-972-2700
Practice Address - Fax:718-532-1724
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000305-1176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01556629Medicaid
NYM5M421Medicare ID - Type Unspecified
NY01556629Medicaid