Provider Demographics
NPI:1659728798
Name:DEGRO VALLADARES, KEISHLA JANICE (MD, FAAP)
Entity Type:Individual
Prefix:
First Name:KEISHLA
Middle Name:JANICE
Last Name:DEGRO VALLADARES
Suffix:
Gender:F
Credentials:MD, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18533 SOLEDAD CANYON RD
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91351-3722
Mailing Address - Country:US
Mailing Address - Phone:661-673-8800
Mailing Address - Fax:
Practice Address - Street 1:18533 SOLEDAD CANYON RD
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91351-3722
Practice Address - Country:US
Practice Address - Phone:616-738-8006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR21334208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty