Provider Demographics
NPI:1174352538
Name:BOCHE-DIAZ, SUSAN (LPN)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BOCHE-DIAZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W DIAMOND AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2180
Mailing Address - Country:US
Mailing Address - Phone:301-549-8438
Mailing Address - Fax:
Practice Address - Street 1:405 W DIAMOND AVE APT 101
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2180
Practice Address - Country:US
Practice Address - Phone:301-549-8438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP52929164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty