Healthcare Provider Details

I. General information

NPI: 1457850141
Provider Name (Legal Business Name): JOHANNELDA JAMORA DIAZ MSN-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 02/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 PENNINGTON RD STE 1
EWING NJ
08618-2669
US

IV. Provider business mailing address

9 ARBOR LN
BORDENTOWN NJ
08505-4808
US

V. Phone/Fax

Practice location:
  • Phone: 609-890-1050
  • Fax:
Mailing address:
  • Phone: 609-491-1321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00790600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: