Provider Demographics
NPI:1639720386
Name:FITZGERALD, HEATHER (RD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:FITZGERALD
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 1:625 MIDVALE AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-2334
Mailing Address - Country:US
Mailing Address - Phone:213-712-6834
Mailing Address - Fax:310-861-1458
Practice Address - Street 1:11633 SAN VICENTE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-6512
Practice Address - Country:US
Practice Address - Phone:213-712-6834
Practice Address - Fax:310-861-1458
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA873919133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA873919OtherREGISTRATION NUMBER