Provider Demographics
NPI:1497298756
Name:STODDARD, BROOKE (RD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:STODDARD
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 1:3370 WATERMARKE PL
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-5618
Mailing Address - Country:US
Mailing Address - Phone:818-726-4583
Mailing Address - Fax:
Practice Address - Street 1:3370 WATERMARKE PL
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-5618
Practice Address - Country:US
Practice Address - Phone:818-726-4583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86001968133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered