Provider Demographics
NPI:1992289094
Name:CARTER, DIESHA DOROTHY
Entity type:Individual
Prefix:
First Name:DIESHA
Middle Name:DOROTHY
Last Name:CARTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 BROADWAY APT 111
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-4316
Mailing Address - Country:US
Mailing Address - Phone:973-900-4910
Mailing Address - Fax:973-497-2708
Practice Address - Street 1:810 BROADWAY APT 111
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-4316
Practice Address - Country:US
Practice Address - Phone:973-900-4910
Practice Address - Fax:973-497-2708
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)