Provider Demographics
NPI:1972857704
Name:DIAZ, SUSANA (CNM)
Entity Type:Individual
Prefix:MRS
First Name:SUSANA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N. NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:621 MEMORIAL DR STE 403
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1074
Practice Address - Country:US
Practice Address - Phone:574-647-1405
Practice Address - Fax:574-647-3970
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000225A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN178420006OtherMEDICARE PTAN
IN201132350Medicaid
IN236040262OtherMEDICARE PTAN