Healthcare Provider Details

I. General information

NPI: 1174359392
Provider Name (Legal Business Name): JENNIFER DIAZ SOBEJANA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 MILLER ST STE C
WINSTON SALEM NC
27104-4206
US

IV. Provider business mailing address

PO BOX 601843
CHARLOTTE NC
28260-1843
US

V. Phone/Fax

Practice location:
  • Phone: 336-310-5535
  • Fax: 336-310-1183
Mailing address:
  • Phone: 336-310-5535
  • Fax: 336-310-1183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5020862
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number280020
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: