Provider Demographics
NPI:1265211882
Name:CEVALLOS, DIANA ALEJANDRA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:ALEJANDRA
Last Name:CEVALLOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11204 DAYLILLY ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-6830
Mailing Address - Country:US
Mailing Address - Phone:909-262-4537
Mailing Address - Fax:
Practice Address - Street 1:499 W ORANGE SHOW RD
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2029
Practice Address - Country:US
Practice Address - Phone:909-379-0003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88652183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist