Provider Demographics
NPI:1194049841
Name:PORTILLO, DIANA (DNP, FNP-C, PMHNP-BC)
Entity type:Individual
Prefix:DR
First Name:DIANA
Middle Name:
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:DNP, FNP-C, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1731
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004-1731
Mailing Address - Country:US
Mailing Address - Phone:575-288-1336
Mailing Address - Fax:575-222-4453
Practice Address - Street 1:330 N CAMPO ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3433
Practice Address - Country:US
Practice Address - Phone:575-288-1336
Practice Address - Fax:575-222-4453
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-01613363LP2300X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM20636865Medicaid
NMNMA100470OtherMEDICARE