Healthcare Provider Details

I. General information

NPI: 1639484876
Provider Name (Legal Business Name): DIANA KATHERINE NIETO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 E OSCEOLA PKWY
KISSIMMEE FL
34744-1605
US

IV. Provider business mailing address

111 WEBB DR
DAVENPORT FL
33837-3944
US

V. Phone/Fax

Practice location:
  • Phone: 844-665-4827
  • Fax:
Mailing address:
  • Phone: 863-421-9447
  • Fax: 863-421-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9103431
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: