Provider Demographics
NPI:1922472562
Name:DIAZ CRUZ, MARIANGELIS
Entity Type:Individual
Prefix:
First Name:MARIANGELIS
Middle Name:
Last Name:DIAZ CRUZ
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 1:1910 WELCH CT
Mailing Address - Street 2:APT. B
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-3405
Mailing Address - Country:US
Mailing Address - Phone:407-910-8584
Mailing Address - Fax:
Practice Address - Street 1:1910 WELCH CT.
Practice Address - Street 2:APT. B
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741
Practice Address - Country:US
Practice Address - Phone:407-910-8584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL171M00000XOtherOTHER SERVICE PROVIDER