MEDICARE: DAWN RAE KIRSTEN DE LA VEGA RDHAP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist	HAP1052	CA
2	124Q00000X	Dental Hygienist	HAP1052	CA

General Provider Information

NPI Number	:	1881450245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAWN RAE KIRSTEN DE LA VEGA RDHAP

Provider Business Mailing Address
First Line	:	PO BOX 557
Second Line	:
City	:	PENN VALLEY
State	:	CA
Zip	:	95946-0557
Country	:	US
Telephone Number	:	530-798-3115
Fax Number	:

Provider Business Practice Location Address
First Line	:	21823 BLUE HORIZON CT
Second Line	:
City	:	BIG OAK VALLEY
State	:	CA
Zip	:	95977-9518
Country	:	US
Telephone Number	:	530-798-3115
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2024
Last Update Date	:	02/23/2024

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