Provider Demographics
NPI:1790475903
Name:OVERLY, CIDNEY (RD)
Entity Type:Individual
Prefix:
First Name:CIDNEY
Middle Name:
Last Name:OVERLY
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 1:6677 SANTA MONICA BLVD APT 3713
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-1690
Mailing Address - Country:US
Mailing Address - Phone:925-548-3475
Mailing Address - Fax:
Practice Address - Street 1:6677 SANTA MONICA BLVD APT 3713
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-1690
Practice Address - Country:US
Practice Address - Phone:925-548-3475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86290663133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered