Provider Demographics
NPI:1639613326
Name:MAGGIORE, MEAGAN MARIE (RD)
Entity Type:Individual
Prefix:
First Name:MEAGAN
Middle Name:MARIE
Last Name:MAGGIORE
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 1:1617 N CALIFORNIA ST STE 2G
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-6117
Mailing Address - Country:US
Mailing Address - Phone:209-461-5268
Mailing Address - Fax:
Practice Address - Street 1:1617 N CALIFORNIA ST STE 2G
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6117
Practice Address - Country:US
Practice Address - Phone:209-461-5268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86030507133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered