Provider Demographics
NPI:1578985560
Name:O'DONNELL, ELOISE (RDN, CDCES)
Entity Type:Individual
Prefix:
First Name:ELOISE
Middle Name:
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:RDN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 28TH ST # A
Mailing Address - Street 2:
Mailing Address - City:HERMOSA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90254-2125
Mailing Address - Country:US
Mailing Address - Phone:310-245-9125
Mailing Address - Fax:310-347-4208
Practice Address - Street 1:419 28TH ST # A
Practice Address - Street 2:
Practice Address - City:HERMOSA BEACH
Practice Address - State:CA
Practice Address - Zip Code:90254-2125
Practice Address - Country:US
Practice Address - Phone:310-245-9125
Practice Address - Fax:310-347-4208
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1013725133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered