Provider Demographics
NPI:1144412156
Name:BROCHU, ANGELA (RD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BROCHU
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 1:180 CALIFORNIA DR
Mailing Address - Street 2:
Mailing Address - City:YOUNTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94599-1411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 CALIFORNIA DR
Practice Address - Street 2:
Practice Address - City:YOUNTVILLE
Practice Address - State:CA
Practice Address - Zip Code:94599-1411
Practice Address - Country:US
Practice Address - Phone:707-944-4862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME884635133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered