Healthcare Provider Details

I. General information

NPI: 1952231011
Provider Name (Legal Business Name): MRS. JOHANA LUISA DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 NEW BRITAIN RD
BERLIN CT
06037-1318
US

IV. Provider business mailing address

363 NEW BRITAIN RD
BERLIN CT
06037-1318
US

V. Phone/Fax

Practice location:
  • Phone: 860-999-5542
  • Fax:
Mailing address:
  • Phone: 860-999-5542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number756
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: