Provider Demographics
NPI:1760787121
Name:DIETZEN, KELLY (LM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DIETZEN
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 CAMPBELL ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91207-1446
Mailing Address - Country:US
Mailing Address - Phone:323-240-4024
Mailing Address - Fax:
Practice Address - Street 1:1327 CAMPBELL ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91207-1446
Practice Address - Country:US
Practice Address - Phone:323-240-4024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-17
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA257176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife