Healthcare Provider Details

I. General information

NPI: 1235057571
Provider Name (Legal Business Name): MS. BIANCA LYZETTE DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 N PRINCE ST
CLOVIS NM
88101-4850
US

IV. Provider business mailing address

4233 LEW WALLACE DR
CLOVIS NM
88101-2539
US

V. Phone/Fax

Practice location:
  • Phone: 956-720-1901
  • Fax:
Mailing address:
  • Phone: 956-720-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberPTA1493
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: