Healthcare Provider Details

I. General information

NPI: 1235703448
Provider Name (Legal Business Name): IVELISSE DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 CARR 2
MANATI PR
00674-5469
US

IV. Provider business mailing address

88 CARR 2
MANATI PR
00674-5469
US

V. Phone/Fax

Practice location:
  • Phone: 787-854-8450
  • Fax: 787-854-8459
Mailing address:
  • Phone: 787-854-8450
  • Fax: 787-854-8459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number8121
License Number StatePR

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: