Provider Demographics
NPI:1114524386
Name:DIAZ, JOHANNY
Entity Type:Individual
Prefix:
First Name:JOHANNY
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 1:6725 SW 137TH CT UNIT 14D
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-2294
Mailing Address - Country:US
Mailing Address - Phone:305-240-7704
Mailing Address - Fax:
Practice Address - Street 1:6725 SW 137TH CT UNIT 14D
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-2294
Practice Address - Country:US
Practice Address - Phone:305-240-7704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9503173163W00000X
FL73839225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse