Provider Demographics
NPI:1144877218
Name:GUTIERREZ, DIANA LEE (AGACNP)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:LEE
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 142
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-0142
Mailing Address - Country:US
Mailing Address - Phone:505-859-9892
Mailing Address - Fax:
Practice Address - Street 1:2210 SUNRANCH VILLAGE LOOP SUITE A
Practice Address - Street 2:SUITE A
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031
Practice Address - Country:US
Practice Address - Phone:505-361-2111
Practice Address - Fax:505-401-4486
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COC-APN.0101302-C-NP363L00000X
NM56997363LA2200X, 363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology