Provider Demographics
NPI:1083472732
Name:DIAZ, MARICELA
Entity Type:Individual
Prefix:
First Name:MARICELA
Middle Name:
Last Name:DIAZ
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 1:407 E GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5325
Mailing Address - Country:US
Mailing Address - Phone:909-889-1136
Mailing Address - Fax:909-889-2816
Practice Address - Street 1:407 E GILBERT ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5325
Practice Address - Country:US
Practice Address - Phone:909-889-1136
Practice Address - Fax:909-889-2816
Is Sole Proprietor?:No
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker