Provider Demographics
NPI:1205560943
Name:ESTRADA DIAZ, GISSELLE
Entity type:Individual
Prefix:
First Name:GISSELLE
Middle Name:
Last Name:ESTRADA 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 1:1083 PLACID DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92878-3702
Mailing Address - Country:US
Mailing Address - Phone:714-860-0147
Mailing Address - Fax:
Practice Address - Street 1:1556 S SULTANA AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-4238
Practice Address - Country:US
Practice Address - Phone:909-418-6923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-09
Last Update Date:2022-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty