Provider Demographics
NPI:1558144154
Name:DIAZ, TERESA M (LVN)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:M
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19606 PARK LN
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93245-3347
Mailing Address - Country:US
Mailing Address - Phone:314-249-3556
Mailing Address - Fax:
Practice Address - Street 1:19606 PARK LN
Practice Address - Street 2:
Practice Address - City:LEMOORE
Practice Address - State:CA
Practice Address - Zip Code:93245-3347
Practice Address - Country:US
Practice Address - Phone:314-249-3556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA221862164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse