Healthcare Provider Details

I. General information

NPI: 1275036584
Provider Name (Legal Business Name): CASSANDRA BETH DIAZ DE LEON DNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3690 S PARK AVE STE 805
TUCSON AZ
85713-5042
US

IV. Provider business mailing address

PO BOX 188
MARANA AZ
85653-0188
US

V. Phone/Fax

Practice location:
  • Phone: 520-616-6760
  • Fax: 520-616-6799
Mailing address:
  • Phone: 520-682-4111
  • Fax: 520-818-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP11155
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN184451
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: