Provider Demographics
NPI:1396889507
Name:SJOSTROM, JOEY LYN (RD)
Entity type:Individual
Prefix:MRS
First Name:JOEY
Middle Name:LYN
Last Name:SJOSTROM
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 1:10961 SHALLOW WATER CT
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-8721
Mailing Address - Country:US
Mailing Address - Phone:702-878-5639
Mailing Address - Fax:480-247-4491
Practice Address - Street 1:8275 S EASTERN AVE
Practice Address - Street 2:SUITE #118
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-2591
Practice Address - Country:US
Practice Address - Phone:702-878-5639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA844423133V00000X
NV38696DI-0133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered