Provider Demographics
NPI:1649787037
Name:FANAEIAN, MANIA (MS, RD, CNSC)
Entity type:Individual
Prefix:
First Name:MANIA
Middle Name:
Last Name:FANAEIAN
Suffix:
Gender:F
Credentials:MS, RD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12910 1/2 ADMIRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6516
Mailing Address - Country:US
Mailing Address - Phone:916-289-8930
Mailing Address - Fax:
Practice Address - Street 1:12910 1/2 ADMIRAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6516
Practice Address - Country:US
Practice Address - Phone:916-289-8930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-07
Last Update Date:2018-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered