Provider Demographics
NPI:1093144529
Name:LOPEZ, PAMELA (RD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:LOPEZ
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 1:8167 VINEYARD AVE APT 83
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3395
Mailing Address - Country:US
Mailing Address - Phone:626-376-8104
Mailing Address - Fax:
Practice Address - Street 1:312 N AZUSA AVE
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-3439
Practice Address - Country:US
Practice Address - Phone:626-633-1500
Practice Address - Fax:626-633-1501
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86009581133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered