Provider Demographics
NPI:1689076929
Name:DIAZ, LISA MARIE (RN, MSN, CDE)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:RN, MSN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1798 N GAREY AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2918
Mailing Address - Country:US
Mailing Address - Phone:909-865-9501
Mailing Address - Fax:909-865-9740
Practice Address - Street 1:1798 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2918
Practice Address - Country:US
Practice Address - Phone:909-865-9501
Practice Address - Fax:909-865-9740
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21700890163WD0400X
CA543304163WC1500X
CA578771163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health