Provider Demographics
NPI:1639764368
Name:DIAZ, JANET (AGPC NP-C)
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:AGPC NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 E HERNDON AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3393
Mailing Address - Country:US
Mailing Address - Phone:559-326-1222
Mailing Address - Fax:559-421-7004
Practice Address - Street 1:12998 HESPERIA RD STE 204
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8317
Practice Address - Country:US
Practice Address - Phone:760-780-4960
Practice Address - Fax:760-780-4964
Is Sole Proprietor?:No
Enumeration Date:2021-03-04
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018207363L00000X
FL11011970363L00000X
FLAPRN11011970363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110690600Medicaid