Provider Demographics
NPI:1164088548
Name:DIAZ, GUADALUPE
Entity Type:Individual
Prefix:
First Name:GUADALUPE
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 1:1205 GRANT AVE S APT N203
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-6025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12900 S HARRIS AVE
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-1723
Practice Address - Country:US
Practice Address - Phone:310-486-0855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-11
Last Update Date:2019-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program