=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588527113
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELICA MARTE DIAZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2025
-----------------------------------------------------
Last Update Date | 12/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 LORRAINE AVE
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10553-1222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-663-7070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 BOGARDUS PL APT 4F
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10040-2252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-541-0055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------