Provider Demographics
NPI:1962674986
Name:LIN, ANGELA Y (RD)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:Y
Last Name:LIN
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:PO BOX 5022
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92248-5022
Mailing Address - Country:US
Mailing Address - Phone:301-233-6711
Mailing Address - Fax:
Practice Address - Street 1:77897 LITTLE EAGLE CT
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-7159
Practice Address - Country:US
Practice Address - Phone:301-233-6711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA508329133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA508329Medicaid
CA508329Medicare PIN