Provider Demographics
NPI:1407600406
Name:HARTOWIDJOJO, MICHELLE (RD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HARTOWIDJOJO
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 1:411 S NORMANDIE AVE APT 501
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-3386
Mailing Address - Country:US
Mailing Address - Phone:213-519-8014
Mailing Address - Fax:
Practice Address - Street 1:411 S NORMANDIE AVE APT 501
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-3386
Practice Address - Country:US
Practice Address - Phone:213-519-8014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86359327133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered