Healthcare Provider Details

I. General information

NPI: 1558352617
Provider Name (Legal Business Name): NENITA S DIEGO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57950 LEAVENWORTH ST 22D MEDICAL GROUP
MCCONNELL AFB KS
67221-3506
US

IV. Provider business mailing address

57950 LEAVENWORTH ST 22D MEDICAL GROUP
MCCONNELL AFB KS
67221-3506
US

V. Phone/Fax

Practice location:
  • Phone: 316-759-5864
  • Fax: 316-759-5038
Mailing address:
  • Phone: 316-759-5864
  • Fax: 316-759-5038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number17124
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number17124
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: