Provider Demographics
NPI:1760863674
Name:DIAZ, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
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:PO BOX 372800
Mailing Address - Street 2:
Mailing Address - City:CAYEY
Mailing Address - State:PR
Mailing Address - Zip Code:00737-2800
Mailing Address - Country:US
Mailing Address - Phone:787-535-1001
Mailing Address - Fax:787-535-1059
Practice Address - Street 1:RR 02 BOX 5342
Practice Address - Street 2:
Practice Address - City:CIDRA
Practice Address - State:PR
Practice Address - Zip Code:00739
Practice Address - Country:US
Practice Address - Phone:787-535-1001
Practice Address - Fax:787-535-1059
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1902133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist