Healthcare Provider Details

I. General information

NPI: 1194341354
Provider Name (Legal Business Name): ROBIN M WONG RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ROBIN M WITHROW-WONG RDN

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51200 PUMPHOUSE ROAD
CLARKSBURG CA
95612
US

IV. Provider business mailing address

PO BOX 369
CLARKSBURG CA
95612-0369
US

V. Phone/Fax

Practice location:
  • Phone: 916-799-4639
  • Fax:
Mailing address:
  • Phone: 916-799-4639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86064294
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: