Provider Demographics
NPI:1902895071
Name:LOPEZ-AGOSTO, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:LOPEZ-AGOSTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:11750 E COLONIAL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-4656
Mailing Address - Country:US
Mailing Address - Phone:203-823-5055
Mailing Address - Fax:
Practice Address - Street 1:11750 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4624
Practice Address - Country:US
Practice Address - Phone:844-665-4827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003135363L00000X
FLARNP9365957363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTQ33867Medicare UPIN
FLHY680ZMedicare PIN
CT500001386Medicare PIN