Provider Demographics
NPI:1568512804
Name:TADIBOYANA, PRABHA (DIETITIAN)
Entity Type:Individual
Prefix:
First Name:PRABHA
Middle Name:
Last Name:TADIBOYANA
Suffix:
Gender:F
Credentials:DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20800 HOMESTEAD RD
Mailing Address - Street 2:APT # 17 G
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-0458
Mailing Address - Country:US
Mailing Address - Phone:408-517-0992
Mailing Address - Fax:
Practice Address - Street 1:1440 168TH AVENUE
Practice Address - Street 2:KAISER POST ACUTE CARE CENTER
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578
Practice Address - Country:US
Practice Address - Phone:510-481-6319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
943807133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered