Provider Demographics
NPI:1083240378
Name:WANG, LI (PHD, RDN)
Entity Type:Individual
Prefix:
First Name:LI
Middle Name:
Last Name:WANG
Suffix:
Gender:F
Credentials:PHD, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:579 MARIPOSA AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94041-1705
Mailing Address - Country:US
Mailing Address - Phone:650-766-8371
Mailing Address - Fax:
Practice Address - Street 1:120 SAN LUCAR CT
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94086-5213
Practice Address - Country:US
Practice Address - Phone:855-816-7705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86013266133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered