Healthcare Provider Details

I. General information

NPI: 1457823346
Provider Name (Legal Business Name): DIANA MARIA MARQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 ORCHARD VILLAS AVE
APEX NC
27502-4338
US

IV. Provider business mailing address

901 DALE CT SE
VIENNA VA
22180-5826
US

V. Phone/Fax

Practice location:
  • Phone: 919-954-4492
  • Fax:
Mailing address:
  • Phone: 703-943-6532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-4934
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP19158
License Number StateNC

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: