Provider Demographics
NPI:1144551003
Name:DIAZ, CARMEN MARIE (RDA)
Entity type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:MARIE
Last Name:DIAZ
Suffix:
Gender:F
Credentials:RDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7241 S MONROE ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-2445
Mailing Address - Country:US
Mailing Address - Phone:253-678-2564
Mailing Address - Fax:
Practice Address - Street 1:7241 S MONROE ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-2445
Practice Address - Country:US
Practice Address - Phone:253-678-2564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAD160049121126800000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No126800000XDental ProvidersDental Assistant