Provider Demographics
NPI:1578217824
Name:BUSTAMANTE, EDLYN (PHD, MPH, RDN, LD)
Entity Type:Individual
Prefix:
First Name:EDLYN
Middle Name:
Last Name:BUSTAMANTE
Suffix:
Gender:F
Credentials:PHD, MPH, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2953 SANDCASTLE LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-5765
Mailing Address - Country:US
Mailing Address - Phone:832-488-9385
Mailing Address - Fax:
Practice Address - Street 1:3315 DELANO ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-3284
Practice Address - Country:US
Practice Address - Phone:713-566-3913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82406133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered