Provider Demographics
NPI:1114425808
Name:MCGANNON, DEIDRE ANN (MHA, RDN)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:ANN
Last Name:MCGANNON
Suffix:
Gender:F
Credentials:MHA, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41349 CRESTA VERDE CT
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-4403
Mailing Address - Country:US
Mailing Address - Phone:630-430-4421
Mailing Address - Fax:
Practice Address - Street 1:40663 MURRIETA HOT SPRINGS RD STE C1
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9015
Practice Address - Country:US
Practice Address - Phone:951-200-6791
Practice Address - Fax:951-200-6797
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA711904133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered