Provider Demographics
NPI:1679658892
Name:KNUDSEN, ANTONIA (RD)
Entity Type:Individual
Prefix:MS
First Name:ANTONIA
Middle Name:
Last Name:KNUDSEN
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 1:727 E FREMONT AVE
Mailing Address - Street 2:FRESNO
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-3940
Mailing Address - Country:US
Mailing Address - Phone:559-459-1672
Mailing Address - Fax:559-459-1058
Practice Address - Street 1:1925 E DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-4821
Practice Address - Country:US
Practice Address - Phone:559-459-1672
Practice Address - Fax:559-459-1058
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA634558133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ26959ZOtherPPIN