Provider Demographics
NPI:1770147829
Name:FASULO, CHRISTINA MARIE (MS RD)
Entity type:Individual
Prefix:MISS
First Name:CHRISTINA
Middle Name:MARIE
Last Name:FASULO
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 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8707
Mailing Address - Fax:
Practice Address - Street 1:100 UCLA MEDICAL PLAZA SUITE 345
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1804
Practice Address - Country:US
Practice Address - Phone:310-208-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86048802133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered