Provider Demographics
NPI:1992294490
Name:VICENTE, MARY JANE DIAZ (RN, CNOR, RNFA)
Entity type:Individual
Prefix:
First Name:MARY JANE
Middle Name:DIAZ
Last Name:VICENTE
Suffix:
Gender:F
Credentials:RN, CNOR, RNFA
Other - Prefix:
Other - First Name:MARY JANE
Other - Middle Name:ENGARAN
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2200 MOUNTAIN RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-2002
Mailing Address - Country:US
Mailing Address - Phone:619-300-1201
Mailing Address - Fax:
Practice Address - Street 1:2400 E 4TH ST
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2026
Practice Address - Country:US
Practice Address - Phone:619-470-4240
Practice Address - Fax:619-470-4400
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA624580163W00000X, 163WM0102X, 163WX0003X
CA1677682364SP2800X
CA000000163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No163W00000XNursing Service ProvidersRegistered Nurse
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient
No364SP2800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPerioperative