Provider Demographics
NPI:1942833132
Name:DIAZ, KELLY JO (CMA AAMA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:DIAZ
Suffix:
Gender:F
Credentials:CMA AAMA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JO
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:KELLY DIAZ CMA AAMA
Mailing Address - Street 1:4922 PORT SHELDON ST
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-8927
Mailing Address - Country:US
Mailing Address - Phone:616-308-9142
Mailing Address - Fax:
Practice Address - Street 1:4922 PORT SHELDON ST
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-8927
Practice Address - Country:US
Practice Address - Phone:616-308-9142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI00000000000000376K00000X
MI376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide