Healthcare Provider Details

I. General information

NPI: 1053512384
Provider Name (Legal Business Name): LOURDES DIAZ-BERGOUIGNAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 SW 8TH ST UNIVERSITY HEALTH SERVICES COMPLEX
MIAMI FL
33199-0001
US

IV. Provider business mailing address

321 SW 104TH CT
MIAMI FL
33174-1647
US

V. Phone/Fax

Practice location:
  • Phone: 305-348-5960
  • Fax:
Mailing address:
  • Phone: 305-223-9865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1400X
TaxonomyCollege Health Registered Nurse
License NumberRN2684682
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: