Basic Information
| Provider Information | |||||||||
| NPI: | 1548725427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | SELENA | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 355 CHARDONNAY AVE | ||||||||
| Address2: | |||||||||
| City: | PROSSER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993509521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097816366 | ||||||||
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| Practice Location | |||||||||
| Address1: | 355 CHARDONNAY AVE | ||||||||
| Address2: | |||||||||
| City: | PROSSER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993509521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097816366 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2019 | ||||||||
| LastUpdateDate: | 01/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP60925995 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.