Provider Demographics
NPI:1982348157
Name:VIG, MYRANDA (RD)
Entity Type:Individual
Prefix:
First Name:MYRANDA
Middle Name:
Last Name:VIG
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:PO BOX 6420
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95763-6420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2521 STOCKTON BLVD # 3200
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2207
Practice Address - Country:US
Practice Address - Phone:916-708-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86170262133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered