Provider Demographics
NPI:1710321997
Name:DIAZ CALLAHAN, LISETTE (RN)
Entity Type:Individual
Prefix:MRS
First Name:LISETTE
Middle Name:
Last Name:DIAZ CALLAHAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 MARC DR
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-2139
Mailing Address - Country:US
Mailing Address - Phone:631-775-6301
Mailing Address - Fax:
Practice Address - Street 1:58 MARC DR
Practice Address - Street 2:
Practice Address - City:RIDGE
Practice Address - State:NY
Practice Address - Zip Code:11961-2139
Practice Address - Country:US
Practice Address - Phone:631-775-6301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY659504163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse