Provider Demographics
NPI:1043431224
Name:OLIVER, AUDREY DAVIS (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:DAVIS
Last Name:OLIVER
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:MS
Other - First Name:AUDREY
Other - Middle Name:IRENE
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:REGISTERED DIETITIAN
Mailing Address - Street 1:61 ALTA VISTA WAY
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94014
Mailing Address - Country:US
Mailing Address - Phone:415-585-0370
Mailing Address - Fax:415-759-3317
Practice Address - Street 1:375 LAGUNA HONDA BLVD
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94116
Practice Address - Country:US
Practice Address - Phone:415-759-3300
Practice Address - Fax:415-759-3317
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA139950133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered