=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992046171
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WANDA IVELISSE DIAZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2013
-----------------------------------------------------
Last Update Date | 03/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 759 AVE AVELINO VICENTE
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00909-2538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-410-5443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2510
-----------------------------------------------------
City | JUNCOS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00777-2510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 930
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------