Provider Demographics
NPI:1063099547
Name:DIAZ, MICHELLE LORENZO (CRNP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LORENZO
Last Name:DIAZ
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:DAYUJA
Other - Last Name:LORENZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:3610 LUPTON CT
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:MD
Mailing Address - Zip Code:20695-4231
Mailing Address - Country:US
Mailing Address - Phone:240-441-2343
Mailing Address - Fax:
Practice Address - Street 1:4475 REGENCY PL STE 303
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:MD
Practice Address - Zip Code:20695-3077
Practice Address - Country:US
Practice Address - Phone:301-645-3420
Practice Address - Fax:301-751-7923
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR183748363LG0600X, 363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care