Provider Demographics
NPI:1881450245
Name:DE LA VEGA, DAWN RAE KIRSTEN (RDHAP)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:RAE KIRSTEN
Last Name:DE LA VEGA
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 557
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95946-0557
Mailing Address - Country:US
Mailing Address - Phone:530-798-3115
Mailing Address - Fax:
Practice Address - Street 1:21823 BLUE HORIZON CT
Practice Address - Street 2:
Practice Address - City:BIG OAK VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95977-9518
Practice Address - Country:US
Practice Address - Phone:530-798-3115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHAP1052133N00000X, 124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
No133N00000XDietary & Nutritional Service ProvidersNutritionist