Healthcare Provider Details

I. General information

NPI: 1295176527
Provider Name (Legal Business Name): DIANA RENEE PUTIGNANO ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA RENEE SMITH

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8930 VILLAGE AVE
SUN VALLEY CA
91352-2129
US

IV. Provider business mailing address

8930 VILLAGE AVE
SUN VALLEY CA
91352-2129
US

V. Phone/Fax

Practice location:
  • Phone: 818-767-8382
  • Fax:
Mailing address:
  • Phone: 818-767-8382
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number070402610
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: