Provider Demographics
NPI:1891295085
Name:GAVIN, BRYNA (MS, CNS)
Entity Type:Individual
Prefix:
First Name:BRYNA
Middle Name:
Last Name:GAVIN
Suffix:
Gender:F
Credentials:MS, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 EL PASO DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90065-4226
Mailing Address - Country:US
Mailing Address - Phone:424-259-0993
Mailing Address - Fax:
Practice Address - Street 1:1122 EL PASO DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90065-4226
Practice Address - Country:US
Practice Address - Phone:424-259-0993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACNS17412133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist