Provider Demographics
NPI:1679654248
Name:DIAZ, ANGELICA (CNP)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 W BAKER AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4414
Mailing Address - Country:US
Mailing Address - Phone:714-535-1415
Mailing Address - Fax:714-635-6771
Practice Address - Street 1:947 S ANAHEIM BLVD
Practice Address - Street 2:SUITE 270
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-5582
Practice Address - Country:US
Practice Address - Phone:714-535-1415
Practice Address - Fax:714-635-6771
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFP-C 15085363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0090750Medicaid
CANP 15085OtherCA NURSE PRACTITIONER #
CAF1104107OtherAAOFNP CERTIFICATE NUMBER
CAMD1304396OtherDEA NUMBER
CAF1104107OtherAAOFNP CERTIFICATE NUMBER