Kelly Ethel Diaz
Individual provider Active NPI Athletic Trainer · La Canada, CA
NPI 1104641059 · NPPES record last updated Sep 14, 2025
Key facts
- NPI
- 1104641059
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Athletic Trainer 2255A2300X
- License
- 2000058035 (CA)
- Practice address
- 200 Foothill Blvd
La Canada, CA 91011-3700 - Phone
- (818) 826-1637
- NPI assigned
- Nov 16, 2024
- Sex
- Female
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 004992 | NY | MD | Optometrist |
| 2000058035 | CA | MD | Athletic Trainer |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | 004992 | NY | |
| Athletic Trainer | 2255A2300X | 2000058035 | CA | Yes |
Addresses
Primary practice location
200 Foothill Blvd
La Canada, CA 91011-3700
Mailing address
200 Foothill Blvd
La Canada, CA 91011-3700
Other providers in La Canada, CA
- Belle Starr Cruz
- Russell Michael Dea
- Anahit S Derian
- Descanso Dermatology Medical Group
- David H Deter
- Jason Edward Dietz
- Joel Doerning
- Drange Hallman Medical Corporation
- DRS. Ho Dental Partnership
- DSC Physical Therapy Inc.
All providers in La Canada, CA · Athletic Trainer in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 14, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.