Provider Demographics
NPI:1083244891
Name:XALTENO VASQUEZ, DIANA (QMHA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:XALTENO VASQUEZ
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:VASQUEZ BANDERAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:36 SW NYE ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-3821
Mailing Address - Country:US
Mailing Address - Phone:541-265-0445
Mailing Address - Fax:
Practice Address - Street 1:51 SW LEE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-3823
Practice Address - Country:US
Practice Address - Phone:541-574-5960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-21
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500775744Medicaid