Provider Demographics
NPI:1699036053
Name:SULISTIOWATI, ALFREDA
Entity Type:Individual
Prefix:
First Name:ALFREDA
Middle Name:
Last Name:SULISTIOWATI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24850 PROSPECT AVE APT D
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2843
Mailing Address - Country:US
Mailing Address - Phone:310-309-1644
Mailing Address - Fax:
Practice Address - Street 1:24850 PROSPECT AVE APT D
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2843
Practice Address - Country:US
Practice Address - Phone:310-309-1644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1099864133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education