Provider Demographics
NPI:1437482932
Name:FAGUNDES, ALICE DALE WATERBURY (MS, RDN)
Entity Type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:DALE WATERBURY
Last Name:FAGUNDES
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:175 N JACKSON AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1909
Mailing Address - Country:US
Mailing Address - Phone:408-568-4181
Mailing Address - Fax:408-516-9042
Practice Address - Street 1:175 N JACKSON AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1909
Practice Address - Country:US
Practice Address - Phone:408-568-4181
Practice Address - Fax:408-516-9042
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA970752133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered