Provider Demographics
NPI:1508364274
Name:KISANUKI, TERESA ELLEN
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ELLEN
Last Name:KISANUKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 KNIGHTON RD
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-9657
Mailing Address - Country:US
Mailing Address - Phone:530-224-3815
Mailing Address - Fax:
Practice Address - Street 1:3400 KNIGHTON RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-9657
Practice Address - Country:US
Practice Address - Phone:530-224-3815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA804167133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered