Provider Demographics
NPI:1871788711
Name:CORSON, DIANA CHARESE (CNM)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:CHARESE
Last Name:CORSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:CORSON
Other - Last Name:FICHTNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5021 SW MARIGOLD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5172
Mailing Address - Country:US
Mailing Address - Phone:503-774-0503
Mailing Address - Fax:
Practice Address - Street 1:6100 NE FOURTH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-6830
Practice Address - Country:US
Practice Address - Phone:360-514-7300
Practice Address - Fax:360-514-7337
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005093367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife