Provider Demographics
NPI:1568488138
Name:DIEZ, MARIE BERNADETTE GASTON (FNP)
Entity Type:Individual
Prefix:
First Name:MARIE BERNADETTE
Middle Name:GASTON
Last Name:DIEZ
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8505 ARLINGTON BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033
Mailing Address - Country:US
Mailing Address - Phone:571-226-5600
Mailing Address - Fax:571-423-5067
Practice Address - Street 1:8505 ARLINGTON BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031
Practice Address - Country:US
Practice Address - Phone:571-226-5600
Practice Address - Fax:571-423-5067
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001135171363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ54517Medicare UPIN