Healthcare Provider Details

I. General information

NPI: 1063078657
Provider Name (Legal Business Name): DIANA P LEYVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2019
Last Update Date: 02/21/2021
Certification Date: 02/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14362 RAMONA BLVD
BALDWIN PARK CA
91706-3241
US

IV. Provider business mailing address

3045 E FLORENCE AVE
HUNTINGTON PARK CA
90255-5837
US

V. Phone/Fax

Practice location:
  • Phone: 626-337-0676
  • Fax:
Mailing address:
  • Phone: 323-587-7771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95011576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: