Provider Demographics
NPI:1609591213
Name:LARSON, TONYA (RD)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:LARSON
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 1:6211 SIERRA AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1216
Mailing Address - Country:US
Mailing Address - Phone:909-472-2107
Mailing Address - Fax:
Practice Address - Street 1:4097 TRAIL CREEK RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-5869
Practice Address - Country:US
Practice Address - Phone:909-472-2107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86091431132700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes132700000XDietary & Nutritional Service ProvidersDietary ManagerGroup - Single Specialty