Provider Demographics
NPI:1598111965
Name:VILLACIS NUNEZ, DIANA SOFIA (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:SOFIA
Last Name:VILLACIS NUNEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 TULLIE RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2309
Mailing Address - Country:US
Mailing Address - Phone:404-785-5437
Mailing Address - Fax:404-785-9096
Practice Address - Street 1:1400 TULLIE RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2309
Practice Address - Country:US
Practice Address - Phone:404-785-5437
Practice Address - Fax:404-785-9096
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2022-07-19
Deactivation Date:2016-12-30
Deactivation Code:
Reactivation Date:2017-04-27
Provider Licenses
StateLicense IDTaxonomies
GA82202208000000X, 2080P0216X
FLTRN23252390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0216XAllopathic & Osteopathic PhysiciansPediatricsPediatric Rheumatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program