Provider Demographics
NPI:1073176467
Name:OTT, HEATHER LYNN (MS, RDN)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:LYNN
Last Name:OTT
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LYNN
Other - Last Name:TSUNODA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RDN
Mailing Address - Street 1:4591 GILA AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-3717
Mailing Address - Country:US
Mailing Address - Phone:619-723-0633
Mailing Address - Fax:
Practice Address - Street 1:4591 GILA AVE APT 12
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-3717
Practice Address - Country:US
Practice Address - Phone:619-723-0633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-21
Last Update Date:2019-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86075988133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty