Provider Demographics
NPI:1376098178
Name:GUEVARA DIAZ, NANCY (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:GUEVARA DIAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17363 SW 137TH PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-6464
Mailing Address - Country:US
Mailing Address - Phone:305-905-0877
Mailing Address - Fax:
Practice Address - Street 1:3201 NW 24TH STREET RD STE 201
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-6913
Practice Address - Country:US
Practice Address - Phone:305-646-1804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-22
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-54609103K00000X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL751310Medicaid