Provider Demographics
NPI:1114998184
Name:DAVIS, DIANE LIBERTO (MSN, FNP)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:LIBERTO
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 182208
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92178-2208
Mailing Address - Country:US
Mailing Address - Phone:619-556-8475
Mailing Address - Fax:
Practice Address - Street 1:BOX 153
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5153
Practice Address - Country:US
Practice Address - Phone:619-556-8475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9671363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily