Healthcare Provider Details

I. General information

NPI: 1710596556
Provider Name (Legal Business Name): KATIA ZOGG RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 09/20/2020
Certification Date: 09/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

359 LAKEPORT BLVD
LAKEPORT CA
95453-5412
US

IV. Provider business mailing address

3386 PRINCETON DR
SANTA ROSA CA
95405-7055
US

V. Phone/Fax

Practice location:
  • Phone: 707-533-2740
  • Fax:
Mailing address:
  • Phone: 707-761-5438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86150035
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: