Provider Demographics
NPI:1073636833
Name:CHAN, TRUDY M (RD)
Entity Type:Individual
Prefix:
First Name:TRUDY
Middle Name:M
Last Name:CHAN
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 1:44049 S EL MACERO DR
Mailing Address - Street 2:
Mailing Address - City:EL MACERO
Mailing Address - State:CA
Mailing Address - Zip Code:95618-1024
Mailing Address - Country:US
Mailing Address - Phone:530-756-1561
Mailing Address - Fax:
Practice Address - Street 1:137 NORTH COTTONWOOD ST.
Practice Address - Street 2:SUITE 1200
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695
Practice Address - Country:US
Practice Address - Phone:530-666-8446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL391007133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered