Provider Demographics
NPI:1558149849
Name:DIAZ BAEZ, CARLA JANISSE (BS)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:JANISSE
Last Name:DIAZ BAEZ
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1734 RAVENWOOD CIR APT E
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-0928
Mailing Address - Country:US
Mailing Address - Phone:407-591-9533
Mailing Address - Fax:
Practice Address - Street 1:1734 RAVENWOOD CIR APT E
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-0928
Practice Address - Country:US
Practice Address - Phone:407-591-9533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator