Provider Demographics
NPI:1922315076
Name:HUTZEZON, PEGGY T (RD, CNSC)
Entity Type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:T
Last Name:HUTZEZON
Suffix:
Gender:F
Credentials:RD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 216
Mailing Address - Street 2:
Mailing Address - City:LOMITA
Mailing Address - State:CA
Mailing Address - Zip Code:90717-0216
Mailing Address - Country:US
Mailing Address - Phone:310-530-2828
Mailing Address - Fax:310-530-5606
Practice Address - Street 1:1748 260TH ST
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-0216
Practice Address - Country:US
Practice Address - Phone:310-530-2828
Practice Address - Fax:310-530-5606
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA887760133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA887760OtherCDR REGISTRATION