Provider Demographics
NPI:1538282983
Name:SEIERSEN, MARY (RDE)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SEIERSEN
Suffix:
Gender:F
Credentials:RDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15464 GOLDENWEST ST
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-6149
Mailing Address - Country:US
Mailing Address - Phone:714-891-9008
Mailing Address - Fax:714-893-2239
Practice Address - Street 1:3851 KATELLA AVE STE 275
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3377
Practice Address - Country:US
Practice Address - Phone:562-296-5528
Practice Address - Fax:562-296-8506
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133V00000X
CA711000163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA711000OtherSTATE LICENSE #