Provider Demographics
NPI:1104912757
Name:ANDERSON, SANDRA JS (RD)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:JS
Last Name:ANDERSON
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 1:94-824 KAAHOLO STREET
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797
Mailing Address - Country:US
Mailing Address - Phone:808-677-0596
Mailing Address - Fax:
Practice Address - Street 1:94-824 KAAHOLO ST
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-1286
Practice Address - Country:US
Practice Address - Phone:808-677-0596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI574596133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI100319Medicare ID - Type Unspecified