Basic Information
| Provider Information | |||||||||
| NPI: | 1053695395 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NEMIROVSKY | ||||||||
| FirstName: | DIANA | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 DISTEL CIR | ||||||||
| Address2: | |||||||||
| City: | LOS ALTOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940221408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102043977 | ||||||||
| FaxNumber: | 5102045429 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 ASHBY AVE RM 3040 | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947052067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102043977 | ||||||||
| FaxNumber: | 5102045429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2011 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 753612 | CA | N | Nursing Service Providers | Registered Nurse | 363L00000X | 21112 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367A00000X | 1963 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 1963 | 01 | AMCB | OTHER | 500645761 | 05 | OR | MEDICAID | R167530 | 01 | OR | PTAN | OTHER | 21112 | 01 | CA | CALIFORNIA BOARD OF NURSING | OTHER | 753612 | 01 | CA | BOARD OF NURSING | OTHER |