Healthcare Provider Details

I. General information

NPI: 1598640062
Provider Name (Legal Business Name): HALEY DIEDRICK DNP, RN, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2025
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 SAN VICENTE BLVD STE 500
LOS ANGELES CA
90048-5455
US

IV. Provider business mailing address

18734 HONEY TREE LN
NORTHVILLE MI
48168-8605
US

V. Phone/Fax

Practice location:
  • Phone: 310-854-0770
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95036514
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number95430562
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: