Provider Demographics
NPI:1326823436
Name:DIAZ GUERRERO, RAISA
Entity Type:Individual
Prefix:
First Name:RAISA
Middle Name:
Last Name:DIAZ GUERRERO
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 1:1129 TRAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-7125
Mailing Address - Country:US
Mailing Address - Phone:239-308-3051
Mailing Address - Fax:
Practice Address - Street 1:1129 TRAVIS AVE
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-7125
Practice Address - Country:US
Practice Address - Phone:239-308-3051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11025544363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner