Healthcare Provider Details

I. General information

NPI: 1316597479
Provider Name (Legal Business Name): DIANA OLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2019
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5003 W. CREEDANCE BLVD.
GLENDALE AZ
85310
US

IV. Provider business mailing address

5003 W. CREEDANCE BLVD.
GLENDALE AZ
85310
US

V. Phone/Fax

Practice location:
  • Phone: 602-882-7355
  • Fax:
Mailing address:
  • Phone: 602-882-7355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: