Provider Demographics
NPI:1386218220
Name:LEWALLEN, TAYLOR JORDAN (RD)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:JORDAN
Last Name:LEWALLEN
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 1:13935 PUTNEY RD
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-3427
Mailing Address - Country:US
Mailing Address - Phone:623-238-3452
Mailing Address - Fax:
Practice Address - Street 1:13935 PUTNEY RD
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-3427
Practice Address - Country:US
Practice Address - Phone:623-238-3452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-15
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8608987133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty