Provider Demographics
NPI:1700611092
Name:DIETZ, KELLIE (COA)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:DIETZ
Suffix:
Gender:F
Credentials:COA
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:DUKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPOA
Mailing Address - Street 1:6443 OAKRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-2233
Mailing Address - Country:US
Mailing Address - Phone:916-204-5672
Mailing Address - Fax:
Practice Address - Street 1:7777 E FREEDOM RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9694
Practice Address - Country:US
Practice Address - Phone:209-946-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic Assistant