Provider Demographics
NPI:1548725427
Name:DIAZ, SELENA (ARNP)
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:DIAZ
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 CHARDONNAY AVE
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-9521
Mailing Address - Country:US
Mailing Address - Phone:509-781-6366
Mailing Address - Fax:
Practice Address - Street 1:355 CHARDONNAY AVE
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-9521
Practice Address - Country:US
Practice Address - Phone:509-781-6366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60925995363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty