Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP2300X | Nurse Practitioner - Primary Care | 95018486 | CA |
NPI | 1043976970 |
---|---|
Provider Name | Ms. Diana Grace Reyes De Leon |
First Address | Sylmar, CA 91342-5161 |
Second Address | Sylmar, CA 91342-5161 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/11/2021 |
Last Update Date | 15/11/2021 |