Provider Demographics
NPI:1255859385
Name:SO, TIANY SIAO TIAN (MS, RD)
Entity Type:Individual
Prefix:
First Name:TIANY
Middle Name:SIAO TIAN
Last Name:SO
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2703 N ONTARIO ST STE 120&130
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-2508
Mailing Address - Country:US
Mailing Address - Phone:657-217-1279
Mailing Address - Fax:
Practice Address - Street 1:2703 N ONTARIO ST STE 120&130
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91504-2508
Practice Address - Country:US
Practice Address - Phone:657-217-1279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86083673133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered