Healthcare Provider Details

I. General information

NPI: 1356289847
Provider Name (Legal Business Name): MELISSA HEATHER DIAZ REYES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 W CENTURY BLVD
INGLEWOOD CA
90304-1504
US

IV. Provider business mailing address

11822 CHANERA AVE
HAWTHORNE CA
90250-1824
US

V. Phone/Fax

Practice location:
  • Phone: 310-671-0555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN95434204
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: