Provider Demographics
NPI:1881770345
Name:DIBBLE, RAQUEL (CNM)
Entity type:Individual
Prefix:MRS
First Name:RAQUEL
Middle Name:
Last Name:DIBBLE
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 1:980 MEDICAL DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3094
Mailing Address - Country:US
Mailing Address - Phone:435-723-6191
Mailing Address - Fax:435-723-7797
Practice Address - Street 1:980 MEDICAL DR
Practice Address - Street 2:SUITE 1
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-3094
Practice Address - Country:US
Practice Address - Phone:435-723-6191
Practice Address - Fax:435-723-7797
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT278411-4402176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT20-1084996OtherTAX ID NUMBER