Provider Demographics
NPI:1184518722
Name:AMAVIZCA, KEILA Y
Entity type:Individual
Prefix:
First Name:KEILA
Middle Name:Y
Last Name:AMAVIZCA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16667 E RADIANT CT
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-1028
Mailing Address - Country:US
Mailing Address - Phone:714-618-0592
Mailing Address - Fax:
Practice Address - Street 1:5601 DE SOTO AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-6798
Practice Address - Country:US
Practice Address - Phone:183-357-4227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20541390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program