Provider Demographics
NPI:1376316737
Name:FAN, LIYAO (RD)
Entity Type:Individual
Prefix:
First Name:LIYAO
Middle Name:
Last Name:FAN
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 1:7315 CARLYLE AVE APT 14
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33141-2606
Mailing Address - Country:US
Mailing Address - Phone:312-975-5852
Mailing Address - Fax:
Practice Address - Street 1:7315 CARLYLE AVE APT 14
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33141-2606
Practice Address - Country:US
Practice Address - Phone:312-975-5852
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND12583133V00000X
086175875133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered