Provider Demographics
NPI:1003671629
Name:CLAVIJO, DIANA ISABEL
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:ISABEL
Last Name:CLAVIJO
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 1:7549 NW GREENSPRING ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-3050
Mailing Address - Country:US
Mailing Address - Phone:954-274-5691
Mailing Address - Fax:
Practice Address - Street 1:7549 NW GREENSPRING ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-3050
Practice Address - Country:US
Practice Address - Phone:954-274-5691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11030622363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care