Provider Demographics
NPI:1376255075
Name:PONCE, DIANA MARIBEL
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIBEL
Last Name:PONCE
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 1:2602 VALLEJO ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-3032
Mailing Address - Country:US
Mailing Address - Phone:323-332-8149
Mailing Address - Fax:
Practice Address - Street 1:2602 VALLEJO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-3032
Practice Address - Country:US
Practice Address - Phone:323-332-8149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer