Provider Demographics
NPI:1275282899
Name:DIEGO, IVANNA
Entity Type:Individual
Prefix:
First Name:IVANNA
Middle Name:
Last Name:DIEGO
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 1:554 CHILTON ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-1629
Mailing Address - Country:US
Mailing Address - Phone:908-337-7820
Mailing Address - Fax:
Practice Address - Street 1:554 CHILTON ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-1629
Practice Address - Country:US
Practice Address - Phone:908-337-7820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-04-14
Deactivation Date:2022-03-23
Deactivation Code:
Reactivation Date:2022-04-14
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency