Provider Demographics
NPI:1891483111
Name:HEREDIA-IBARRA, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:HEREDIA-IBARRA
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 1:3512 NE 104TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-5729
Mailing Address - Country:US
Mailing Address - Phone:360-843-8164
Mailing Address - Fax:
Practice Address - Street 1:3512 NE 104TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-5729
Practice Address - Country:US
Practice Address - Phone:360-843-8164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter