Provider Demographics
NPI:1093699845
Name:DIAZ, JANELIS
Entity type:Individual
Prefix:
First Name:JANELIS
Middle Name:
Last Name:DIAZ
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5241 STAFFORD RD
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33565-6143
Mailing Address - Country:US
Mailing Address - Phone:813-422-0793
Mailing Address - Fax:
Practice Address - Street 1:5241 STAFFORD RD
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33565-6143
Practice Address - Country:US
Practice Address - Phone:813-422-0793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-04
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLG632420827240172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver