Provider Demographics
NPI:1043404379
Name:TEDDY, SERENA (PA-C, MS, RD)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:TEDDY
Suffix:
Gender:F
Credentials:PA-C, MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9918 KATELLA AVE STE C
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-6466
Mailing Address - Country:US
Mailing Address - Phone:714-625-8320
Mailing Address - Fax:
Practice Address - Street 1:9918 KATELLA AVE STE C
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-6466
Practice Address - Country:US
Practice Address - Phone:714-625-8320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00969551133V00000X
CA51359363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered