Provider Demographics
NPI:1942436019
Name:LUSTRICK, ANGELA M (CN, CPT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:LUSTRICK
Suffix:
Gender:F
Credentials:CN, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5225 CANYON CREST DR
Mailing Address - Street 2:SUITE #62
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-6301
Mailing Address - Country:US
Mailing Address - Phone:951-683-0448
Mailing Address - Fax:951-683-4381
Practice Address - Street 1:5225 CANYON CREST DR
Practice Address - Street 2:SUITE #62
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-6301
Practice Address - Country:US
Practice Address - Phone:951-683-0448
Practice Address - Fax:951-683-4381
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA02907133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist