Provider Demographics
NPI:1215642707
Name:DIAZ, SUSANA (VN 218123)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:VN 218123
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16921 E AVENUE O STE G
Mailing Address - Street 2:
Mailing Address - City:LAKE LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:93591-3045
Mailing Address - Country:US
Mailing Address - Phone:661-225-3105
Mailing Address - Fax:661-524-2942
Practice Address - Street 1:16921 E AVENUE O STE G
Practice Address - Street 2:
Practice Address - City:LAKE LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:93591-3045
Practice Address - Country:US
Practice Address - Phone:661-225-3105
Practice Address - Fax:661-524-2942
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN218123164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse