Provider Demographics
NPI:1841610219
Name:DIAZ, JUDITH LYNN (AMHNP-BC)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:LYNN
Last Name:DIAZ
Suffix:
Gender:F
Credentials:AMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5134 MEADOW WAY
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-3335
Mailing Address - Country:US
Mailing Address - Phone:951-250-5007
Mailing Address - Fax:
Practice Address - Street 1:5134 MEADOW WAY
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3335
Practice Address - Country:US
Practice Address - Phone:951-250-5007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54007163WP0809X, 363LP0808X
CA95000797363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult