Healthcare Provider Details

I. General information

NPI: 1245878024
Provider Name (Legal Business Name): ANGELIQUE MARIAH DIAZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2019
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27343 WESLEY CHAPEL BLVD
WESLEY CHAPEL FL
33544-4287
US

IV. Provider business mailing address

38135 MARKET SQ
ZEPHYRHILLS FL
33542-7505
US

V. Phone/Fax

Practice location:
  • Phone: 813-991-9355
  • Fax: 813-355-5031
Mailing address:
  • Phone: 352-567-0188
  • Fax: 813-355-5101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11005015
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: