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General NPI Number Information
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NPI Number | 1104641059
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Entity Type | Individual
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Provider Name | KELLY ETHEL DIAZ
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Gender | Female
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Dates
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Enumeration Date | 11/16/2024
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Last Update Date | 09/14/2025
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Provider Practice Location Address
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Address Line | 200 FOOTHILL BLVD
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City | LA CANADA
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State | CA
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Zip | 91011-3700
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Country | US
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Telephone | 818-826-1637
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Fax |
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Provider Business Mailing Address
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Address Line | 200 FOOTHILL BLVD
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City | LA CANADA
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State | CA
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Zip | 91011-3700
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 004992
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2000058035
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License Number State | CA
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