MEDICARE: BLANCA L AVALOS-DIAZ FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	95014670	CA

General Provider Information

NPI Number	:	1114534997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLANCA L AVALOS-DIAZ FNP

Provider Business Mailing Address
First Line	:	11708 NOVA ST
Second Line	:
City	:	SANTA FE SPRINGS
State	:	CA
Zip	:	90670-2837
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11708 NOVA ST
Second Line	:
City	:	SANTA FE SPRINGS
State	:	CA
Zip	:	90670-2837
Country	:	US
Telephone Number	:	323-697-9349
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2020
Last Update Date	:	03/10/2026

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