Provider Demographics
NPI:1194450783
Name:FLORES, DIANA
Entity type:Individual
Prefix:MISS
First Name:DIANA
Middle Name:
Last Name:FLORES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EDWA
Other - Middle Name:
Other - Last Name:SENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2080 W EMPIRE AVE # 1073
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-3434
Mailing Address - Country:US
Mailing Address - Phone:414-578-6651
Mailing Address - Fax:
Practice Address - Street 1:1256 DUARTE RD
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010
Practice Address - Country:US
Practice Address - Phone:414-578-6651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPT-01011070156F00000X
CA95107388163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No156F00000XEye and Vision Services ProvidersTechnician/Technologist