Healthcare Provider Details

I. General information

NPI: 1346882800
Provider Name (Legal Business Name): MRS. LETICIA MARAVILLA DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2019
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1853 LANDER AVE
TURLOCK CA
95380-6240
US

IV. Provider business mailing address

7471 N FRESNO ST
FRESNO CA
93720-2457
US

V. Phone/Fax

Practice location:
  • Phone: 209-656-1617
  • Fax: 209-656-1626
Mailing address:
  • Phone: 559-436-4500
  • Fax: 559-261-1526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: