Provider Demographics
NPI:1598640062
Name:DIEDRICK, HALEY (DNP, RN, CPNP-PC)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:DIEDRICK
Suffix:
Gender:F
Credentials:DNP, RN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18734 HONEY TREE LN
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-8605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6330 SAN VICENTE BLVD STE 500
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5455
Practice Address - Country:US
Practice Address - Phone:310-854-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95430562163WP0200X
CA95036514363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics