Provider Demographics
NPI:1780698217
Name:DIAMOND, MARYANNE (CNM)
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:DIAMOND
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 1:3400 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4238
Mailing Address - Country:US
Mailing Address - Phone:215-662-2730
Mailing Address - Fax:215-349-5224
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:1 WEST GATES
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4238
Practice Address - Country:US
Practice Address - Phone:215-662-2730
Practice Address - Fax:215-349-5224
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW008386L367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019719640004Medicaid
PA0019719640004Medicaid
PA073703Medicare PIN