Provider Demographics
NPI:1902376304
Name:RYAVEC-GORANSON, ILANA CELESTE (RD)
Entity Type:Individual
Prefix:
First Name:ILANA
Middle Name:CELESTE
Last Name:RYAVEC-GORANSON
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 1:270 WYLDEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MURPHYS
Mailing Address - State:CA
Mailing Address - Zip Code:95247-9502
Mailing Address - Country:US
Mailing Address - Phone:209-559-2228
Mailing Address - Fax:
Practice Address - Street 1:488 MAIN ST STE 200B
Practice Address - Street 2:
Practice Address - City:MURPHYS
Practice Address - State:CA
Practice Address - Zip Code:95247-9384
Practice Address - Country:US
Practice Address - Phone:209-559-2228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19258225700000X
CA86112557133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist