Provider Demographics
NPI:1073218681
Name:HERNANDEZ, DIANA MARIE (COTA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:NC
Mailing Address - Zip Code:27962-1823
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1341 PARADISE RD
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-8503
Practice Address - Country:US
Practice Address - Phone:252-482-7481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15763224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant