Provider Demographics
NPI:1922308428
Name:DIAZ, JENNIFER (LPN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-1906
Mailing Address - Country:US
Mailing Address - Phone:631-355-1960
Mailing Address - Fax:
Practice Address - Street 1:393 EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-1906
Practice Address - Country:US
Practice Address - Phone:631-355-1960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-30
Last Update Date:2010-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303305-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse