Provider Demographics
NPI:1760099097
Name:ALONSO STREET, ELLEN M (MS, RD)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:M
Last Name:ALONSO STREET
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:M
Other - Last Name:STREET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD
Mailing Address - Street 1:2628 INTERNATIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-1512
Mailing Address - Country:US
Mailing Address - Phone:105-261-8219
Mailing Address - Fax:
Practice Address - Street 1:2628 INTERNATIONAL BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-1512
Practice Address - Country:US
Practice Address - Phone:105-261-8219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2023-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86176658133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered