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General NPI Number Information
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NPI Number | 1730755380
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Entity Type | Individual
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Provider Name | LISSETTE DIAZ-SERRANO
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Gender | Female
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Dates
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Enumeration Date | 06/02/2021
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Last Update Date | 04/22/2025
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Provider Practice Location Address
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Address Line | 2053 W BIRCHWOOD AVE APT 3
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City | CHICAGO
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State | IL
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Zip | 60645-2173
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Country | US
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Telephone | 773-706-6197
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Fax |
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Provider Business Mailing Address
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Address Line | 2053 W BIRCHWOOD AVE APT 3
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City | CHICAGO
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State | IL
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Zip | 60645-2173
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Country | US
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Telephone | 773-706-6197
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 22344
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License Number State | PR
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