Healthcare Provider Details

I. General information

NPI: 1124182605
Provider Name (Legal Business Name): SALLY ANNE ZUMWALT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10080 N WOLFE RD SUITE SW3-160
CUPERTINO CA
95014-2515
US

IV. Provider business mailing address

1576 MIZZEN LN
HALF MOON BAY CA
94019-1536
US

V. Phone/Fax

Practice location:
  • Phone: 408-342-6699
  • Fax:
Mailing address:
  • Phone: 650-726-6738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number654928
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: