Provider Demographics
NPI:1558016337
Name:DIAZ, GISEL
Entity type:Individual
Prefix:
First Name:GISEL
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 EVANS LN
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-3838
Mailing Address - Country:US
Mailing Address - Phone:540-826-2221
Mailing Address - Fax:
Practice Address - Street 1:52 EVANS LN
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-3838
Practice Address - Country:US
Practice Address - Phone:540-826-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-19
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program