Provider Demographics
NPI:1619424405
Name:BLANDON, MARIA JIMENA (RD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:JIMENA
Last Name:BLANDON
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 1:1909 SCENIC DR APT 202
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4937
Mailing Address - Country:US
Mailing Address - Phone:209-765-2305
Mailing Address - Fax:
Practice Address - Street 1:5425 POMONA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1716
Practice Address - Country:US
Practice Address - Phone:323-728-0411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-08
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1082172133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered