Provider Demographics
NPI:1518307396
Name:RODRIGUEZ, AILEEN MAYTE
Entity Type:Individual
Prefix:
First Name:AILEEN
Middle Name:MAYTE
Last Name:RODRIGUEZ
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 1:1092 ADOBE CANYON RD
Mailing Address - Street 2:
Mailing Address - City:KENWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:95452-9053
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1450 GUERNEVILLE RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-4107
Practice Address - Country:US
Practice Address - Phone:707-565-6595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85002343133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered