Basic Information
| Provider Information | |||||||||
| NPI: | 1801482260 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | JEERIKA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5151 ADANSON ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328041330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078753700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 206 PARK PLACE BLVD | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347412344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078460023 | ||||||||
| FaxNumber: | 4079304348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2020 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | APRN11010296 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LF0000X | APRN11010296 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 109715500 | 05 | FL | MEDICAID |