Provider Demographics
NPI:1154501427
Name:DIAZ, MICHELLE LEE (PA-C, RD)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LEE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:PA-C, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CENTURY DR
Mailing Address - Street 2:
Mailing Address - City:PARSIPPANY
Mailing Address - State:NJ
Mailing Address - Zip Code:07054-4610
Mailing Address - Country:US
Mailing Address - Phone:973-251-1062
Mailing Address - Fax:
Practice Address - Street 1:201 LYONS AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2027
Practice Address - Country:US
Practice Address - Phone:973-926-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X
NJ955344133V00000X
NJ25MP00338800146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered