Provider Demographics
NPI:1245688001
Name:MORAN DIAZ, JENNY MARIANA (RBT)
Entity type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:MARIANA
Last Name:MORAN DIAZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:MRS
Other - First Name:JENNY
Other - Middle Name:MARIANA
Other - Last Name:DIAZ MORAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:JENNY MARIANA MORAN
Mailing Address - Street 1:2101 NE 68TH ST APT 201
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1119
Mailing Address - Country:US
Mailing Address - Phone:561-926-0149
Mailing Address - Fax:
Practice Address - Street 1:5420 NW 33RD AVE STE 101
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-6348
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2022-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018732400Medicaid