Provider Demographics
NPI:1932814043
Name:DIAZ, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name: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 1:2311 N ORANGE BLOSSOM TRL
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-2313
Mailing Address - Country:US
Mailing Address - Phone:407-346-4925
Mailing Address - Fax:
Practice Address - Street 1:2311 N ORANGE BLOSSOM TRL
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-2313
Practice Address - Country:US
Practice Address - Phone:407-346-4925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11023900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner