Provider Demographics
NPI:1346882800
Name:DIAZ, LETICIA MARAVILLA
Entity Type:Individual
Prefix:MRS
First Name:LETICIA
Middle Name:MARAVILLA
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 1:2339 W HAMMER LN STE A
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-2368
Mailing Address - Country:US
Mailing Address - Phone:209-940-5901
Mailing Address - Fax:
Practice Address - Street 1:2339 W HAMMER LN STE A
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-2368
Practice Address - Country:US
Practice Address - Phone:209-940-5901
Practice Address - Fax:209-336-0275
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-16
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant