Provider Demographics
NPI:1669166401
Name:BLANCO, SHANE MARIE SANTOS (RD)
Entity type:Individual
Prefix:
First Name:SHANE MARIE
Middle Name:SANTOS
Last Name:BLANCO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:SHANE MARIE
Other - Middle Name:
Other - Last Name:SANTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:13652 CANTARA ST
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-5423
Mailing Address - Country:US
Mailing Address - Phone:818-383-7691
Mailing Address - Fax:
Practice Address - Street 1:13652 CANTARA ST RM 12R32A
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-5423
Practice Address - Country:US
Practice Address - Phone:818-383-7691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1088065133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered