Provider Demographics
NPI:1497156350
Name:DONKERSLOOT, MARY (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DONKERSLOOT
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 1:462 N LINDEN DR
Mailing Address - Street 2:SUITE 445
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90212-2247
Mailing Address - Country:US
Mailing Address - Phone:310-275-9241
Mailing Address - Fax:310-276-3677
Practice Address - Street 1:462 N LINDEN DR
Practice Address - Street 2:SUITE 445
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-2247
Practice Address - Country:US
Practice Address - Phone:310-275-9241
Practice Address - Fax:310-276-3677
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA529618133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered