Provider Demographics
NPI:1629498548
Name:ANDRESTAYLOR, CORALYN (RD, MPH, CHES)
Entity Type:Individual
Prefix:
First Name:CORALYN
Middle Name:
Last Name:ANDRESTAYLOR
Suffix:
Gender:F
Credentials:RD, MPH, CHES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2254 MICHELTORENA ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90039-3021
Mailing Address - Country:US
Mailing Address - Phone:323-667-2642
Mailing Address - Fax:
Practice Address - Street 1:637 LUCAS AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1997
Practice Address - Country:US
Practice Address - Phone:213-977-2155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-17
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133NN1002X
CA689776133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education