Provider Demographics
NPI:1316720709
Name:DIAZ DIAZ, NELLIE I (PWS)
Entity type:Individual
Prefix:
First Name:NELLIE
Middle Name:I
Last Name:DIAZ DIAZ
Suffix:
Gender:F
Credentials:PWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3652 SUNNYVIEW RD NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1016
Mailing Address - Country:US
Mailing Address - Phone:503-302-5650
Mailing Address - Fax:
Practice Address - Street 1:1011 COMMERCIAL ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-1049
Practice Address - Country:US
Practice Address - Phone:503-983-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000109409175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist