Provider Demographics
NPI:1831290659
Name:DIAZ, ANTONIA (CNA)
Entity Type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11031 NE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-7182
Mailing Address - Country:US
Mailing Address - Phone:305-398-6100
Mailing Address - Fax:305-757-4465
Practice Address - Street 1:1905 NW 82ND AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1011
Practice Address - Country:US
Practice Address - Phone:305-406-9585
Practice Address - Fax:305-406-9478
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA41175376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000755300Medicaid