Provider Demographics
NPI:1720286602
Name:COULSON, DIANA NICHOLS (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:NICHOLS
Last Name:COULSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:393 E WALNUT ST
Mailing Address - Street 2:3RD FLOOR - PHR SYSTEMS
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:626-405-7914
Mailing Address - Fax:626-405-6768
Practice Address - Street 1:9961 SIERRA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:909-427-3910
Practice Address - Fax:626-405-6768
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97361207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine