Provider Demographics
NPI:1376869123
Name:DIAZ, SHANNA VAUGHAN (DO)
Entity Type:Individual
Prefix:MRS
First Name:SHANNA
Middle Name:VAUGHAN
Last Name:DIAZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:SHANNA
Other - Middle Name:LEIGH
Other - Last Name:VAUGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:1101 MEDICAL ARTS AVE NE BLDG 2
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2723
Practice Address - Country:US
Practice Address - Phone:505-272-6110
Practice Address - Fax:505-272-6112
Is Sole Proprietor?:No
Enumeration Date:2010-04-19
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1690-122084P0800X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry