Provider Demographics
NPI:1295200061
Name:HANSEN, SYDNEY BREE (MS, RD)
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:BREE
Last Name:HANSEN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 MURRAY DRIVE
Mailing Address - Street 2:P.O. BOX 779
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201
Mailing Address - Country:US
Mailing Address - Phone:209-373-2800
Mailing Address - Fax:
Practice Address - Street 1:2151 W GRANT LINE RD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95377-7309
Practice Address - Country:US
Practice Address - Phone:209-820-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86080492133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered