Provider Demographics
NPI:1629692470
Name:PORTILLO, DIANA (RN BSN)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 LAUREL ST APT 10
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1049
Mailing Address - Country:US
Mailing Address - Phone:508-762-6023
Mailing Address - Fax:
Practice Address - Street 1:19 TACOMA ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3516
Practice Address - Country:US
Practice Address - Phone:508-852-1805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-07
Last Update Date:2020-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2340199163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Multi-Specialty