Provider Demographics
NPI:1962449306
Name:HEUBUSCH, DIANE D (CNM)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:D
Last Name:HEUBUSCH
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 1:1220 EAST 3900 SOUTH
Mailing Address - Street 2:SUITE 3E
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124
Mailing Address - Country:US
Mailing Address - Phone:801-685-7188
Mailing Address - Fax:801-685-8116
Practice Address - Street 1:1220 EAST 3900 SOUTH
Practice Address - Street 2:SUITE 3E
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-685-7188
Practice Address - Fax:801-685-8116
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2146284402367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
S20110Medicare UPIN
005566103Medicare ID - Type Unspecified