Healthcare Provider Details

I. General information

NPI: 1104641059
Provider Name (Legal Business Name): KELLY ETHEL DIAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2024
Last Update Date: 09/14/2025
Certification Date: 09/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FOOTHILL BLVD
LA CANADA CA
91011-3700
US

IV. Provider business mailing address

200 FOOTHILL BLVD
LA CANADA CA
91011-3700
US

V. Phone/Fax

Practice location:
  • Phone: 818-826-1637
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number004992
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000058035
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: