Provider Demographics
NPI:1811656911
Name:MANTOS, DIANE (RN, BSN, CCM)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:MANTOS
Suffix:
Gender:F
Credentials:RN, BSN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 NW 136TH AVE
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2800
Mailing Address - Country:US
Mailing Address - Phone:757-270-2452
Mailing Address - Fax:770-723-8586
Practice Address - Street 1:12150 MONUMENT DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-4051
Practice Address - Country:US
Practice Address - Phone:757-270-2452
Practice Address - Fax:770-723-8586
Is Sole Proprietor?:No
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001105385163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management