Provider Demographics
NPI:1174302707
Name:DIAMOND MIND & BODY
Entity type:Organization
Organization Name:DIAMOND MIND & BODY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/APN
Authorized Official - Prefix:
Authorized Official - First Name:NWAMAKA
Authorized Official - Middle Name:
Authorized Official - Last Name:ONYEOGO
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:888-574-7165
Mailing Address - Street 1:1309 COFFEEN AVE STE 1200
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-5777
Mailing Address - Country:US
Mailing Address - Phone:888-574-7165
Mailing Address - Fax:888-236-3234
Practice Address - Street 1:28 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10005-1400
Practice Address - Country:US
Practice Address - Phone:888-574-7165
Practice Address - Fax:888-236-3234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-25
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty