Provider Demographics
NPI:1235494154
Name:GANT, PHAIK-JUNE (RD)
Entity Type:Individual
Prefix:
First Name:PHAIK-JUNE
Middle Name:
Last Name:GANT
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 1:115 W HILLSDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-4279
Mailing Address - Country:US
Mailing Address - Phone:650-573-2686
Mailing Address - Fax:
Practice Address - Street 1:222 W 39TH AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-4364
Practice Address - Country:US
Practice Address - Phone:650-573-2686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA985348133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered