Provider Demographics
NPI:1063825099
Name:FORNER, ALESHA (RD)
Entity Type:Individual
Prefix:
First Name:ALESHA
Middle Name:
Last Name:FORNER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 CALIFORNIA DR
Mailing Address - Street 2:
Mailing Address - City:YOUNTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94599-1411
Mailing Address - Country:US
Mailing Address - Phone:707-944-4862
Mailing Address - Fax:707-948-3332
Practice Address - Street 1:100 CALIFORNIA DR
Practice Address - Street 2:
Practice Address - City:YOUNTVILLE
Practice Address - State:CA
Practice Address - Zip Code:94599-1411
Practice Address - Country:US
Practice Address - Phone:707-944-4862
Practice Address - Fax:707-948-3332
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1060922133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered