Healthcare Provider Details

I. General information

NPI: 1760787121
Provider Name (Legal Business Name): KELLY DIETZEN LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2011
Last Update Date: 01/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1327 CAMPBELL ST
GLENDALE CA
91207-1446
US

IV. Provider business mailing address

1327 CAMPBELL ST
GLENDALE CA
91207-1446
US

V. Phone/Fax

Practice location:
  • Phone: 323-240-4024
  • Fax:
Mailing address:
  • Phone: 323-240-4024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number257
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: