Basic Information
| Provider Information | |||||||||
| NPI: | 1386823318 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIRKS | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DIRKS | ||||||||
| OtherFirstName: | DEE DEE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CNM | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1011 BALDWIN PARK BLVD | ||||||||
| Address2: | OB GYN | ||||||||
| City: | BALDWIN PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917065806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268511011 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1011 BALDWIN PARK BLVD | ||||||||
| Address2: | OB GYN | ||||||||
| City: | BALDWIN PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917065806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268511011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2007 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | 722 | CA | Y | Other Service Providers | Midwife |
No ID Information.