Provider Demographics
NPI:1487964656
Name:SAN JUAN, DIANA LIZBETH (QMHA)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:LIZBETH
Last Name:SAN JUAN
Suffix:
Gender:F
Credentials:QMHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 E ELM CT
Mailing Address - Street 2:
Mailing Address - City:GERVAIS
Mailing Address - State:OR
Mailing Address - Zip Code:97026-9780
Mailing Address - Country:US
Mailing Address - Phone:971-218-0951
Mailing Address - Fax:
Practice Address - Street 1:2421 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1220
Practice Address - Country:US
Practice Address - Phone:503-361-2720
Practice Address - Fax:503-585-4990
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator