Provider Demographics
NPI:1629644216
Name:DIAZ, BETHANY VICTORIA
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:VICTORIA
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2475 N JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44052-2443
Mailing Address - Country:US
Mailing Address - Phone:440-670-2611
Mailing Address - Fax:
Practice Address - Street 1:840 DEER RUN DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:OH
Practice Address - Zip Code:44001-2550
Practice Address - Country:US
Practice Address - Phone:440-799-1140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide