Provider Demographics
NPI:1861852592
Name:WAN, CHRISTINE
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:
Last Name:WAN
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 1:126 S CATALINA AVE UNIT 202
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2908
Mailing Address - Country:US
Mailing Address - Phone:626-589-8330
Mailing Address - Fax:
Practice Address - Street 1:126 S CATALINA AVE UNIT 202
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2908
Practice Address - Country:US
Practice Address - Phone:626-589-8330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA916269133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered