Provider Demographics
NPI:1962032045
Name:SANTOSO, ERVA (RDN)
Entity Type:Individual
Prefix:
First Name:ERVA
Middle Name:
Last Name:SANTOSO
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 444 BOX 1082
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96297
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:UNIT 15245
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271-5245
Practice Address - Country:US
Practice Address - Phone:315-737-2377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-17
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1072186133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered