Provider Demographics
NPI:1346896339
Name:PHAN, THAO T (RDN)
Entity Type:Individual
Prefix:
First Name:THAO
Middle Name:T
Last Name:PHAN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9692 DELAFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-3610
Mailing Address - Country:US
Mailing Address - Phone:714-369-9378
Mailing Address - Fax:
Practice Address - Street 1:9692 DELAFIELD CIR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-3610
Practice Address - Country:US
Practice Address - Phone:714-369-9378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86046219133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered