Provider Demographics
NPI:1750574414
Name:DIEZ, TERESA S (CRNP)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:S
Last Name:DIEZ
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 S 2ND ST
Mailing Address - Street 2:SUITE 2F
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 N 3RD ST FL 3
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-1904
Practice Address - Country:US
Practice Address - Phone:717-782-4785
Practice Address - Fax:717-782-6471
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP-001038B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102734116Medicaid
PA2071176OtherHIGHMARK BLUE SHIELD-WMG
MD968826OtherCAREFIRST MD BCBS-WMG
PA2071176OtherHIGHMARK BLUE SHIELD-WMG