Healthcare Provider Details

I. General information

NPI: 1811656911
Provider Name (Legal Business Name): DIANE MANTOS RN, BSN, CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2021
Last Update Date: 12/16/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12150 MONUMENT DR
FAIRFAX VA
22033-4051
US

IV. Provider business mailing address

1391 NW 136TH AVE
SUNRISE FL
33323-2800
US

V. Phone/Fax

Practice location:
  • Phone: 757-270-2452
  • Fax: 770-723-8586
Mailing address:
  • Phone: 757-270-2452
  • Fax: 770-723-8586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number0001105385
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: