Healthcare Provider Details

I. General information

NPI: 1730534843
Provider Name (Legal Business Name): JENNA NATALIA DIAZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 08/03/2025
Certification Date: 08/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3196 S MARYLAND PKWY STE 309
LAS VEGAS NV
89109-2314
US

IV. Provider business mailing address

3196 S MARYLAND PKWY STE 309
LAS VEGAS NV
89109-2314
US

V. Phone/Fax

Practice location:
  • Phone: 702-791-0477
  • Fax: 702-791-6831
Mailing address:
  • Phone: 702-791-0477
  • Fax: 702-791-6831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2019017047
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number22162
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: