Provider Demographics
NPI:1528586617
Name:BOCCANFUSO, JUDITH (RD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:BOCCANFUSO
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 1:2301 CIRCADIAN WAY STE A
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-5457
Mailing Address - Country:US
Mailing Address - Phone:707-526-2027
Mailing Address - Fax:707-526-2096
Practice Address - Street 1:2301 CIRCADIAN WAY STE A
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5457
Practice Address - Country:US
Practice Address - Phone:707-526-2027
Practice Address - Fax:707-526-2096
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA376854133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered