Provider Demographics
NPI:1184094807
Name:DIAZ, KARINA ALEXANDRA
Entity type:Individual
Prefix:
First Name:KARINA
Middle Name:ALEXANDRA
Last Name:DIAZ
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 1:571 BROOKHAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-1675
Mailing Address - Country:US
Mailing Address - Phone:631-336-0641
Mailing Address - Fax:
Practice Address - Street 1:571 BROOKHAVEN AVE
Practice Address - Street 2:
Practice Address - City:BELLPORT
Practice Address - State:NY
Practice Address - Zip Code:11713-1675
Practice Address - Country:US
Practice Address - Phone:631-336-0641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3236371164W00000X
NY807394163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse