MEDICARE: RAISA DIAZ GUERRERO

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	363L00000X	Nurse Practitioner	11025544	FL

General Provider Information

NPI Number	:	1326823436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAISA DIAZ GUERRERO

Provider Business Mailing Address
First Line	:	1129 TRAVIS AVE
Second Line	:
City	:	NORTH FORT MYERS
State	:	FL
Zip	:	33903-7125
Country	:	US
Telephone Number	:	239-308-3051
Fax Number	:

Provider Business Practice Location Address
First Line	:	1129 TRAVIS AVE
Second Line	:
City	:	NORTH FORT MYERS
State	:	FL
Zip	:	33903-7125
Country	:	US
Telephone Number	:	239-308-3051
Fax Number	:

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

Provider Enumeration Date	:	08/28/2023
Last Update Date	:	08/28/2023

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