Provider Demographics
NPI:1548422231
Name:DAMAYANTI, ASTRIN P (RD)
Entity Type:Individual
Prefix:
First Name:ASTRIN
Middle Name:P
Last Name:DAMAYANTI
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 1:10940 TRINITY PKWY STE C305
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7234
Mailing Address - Country:US
Mailing Address - Phone:209-715-5858
Mailing Address - Fax:
Practice Address - Street 1:10940 TRINITY PKWY STE C305
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-7234
Practice Address - Country:US
Practice Address - Phone:209-715-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
961513133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
961513OtherCOMMISSION ON DIETETIC REGISTRATION