Healthcare Provider Details

I. General information

NPI: 1629692470
Provider Name (Legal Business Name): DIANA PORTILLO RN BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2020
Last Update Date: 06/07/2020
Certification Date: 06/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 TACOMA ST
WORCESTER MA
01605-3516
US

IV. Provider business mailing address

7 LAUREL ST APT 10
WORCESTER MA
01608-1049
US

V. Phone/Fax

Practice location:
  • Phone: 508-852-1805
  • Fax:
Mailing address:
  • Phone: 508-762-6023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN2340199
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: