Healthcare Provider Details

I. General information

NPI: 1003605734
Provider Name (Legal Business Name): WALESKA MEDINA-CANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2025
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 W CESAR E CHAVEZ AVE
LOS ANGELES CA
90012-2104
US

IV. Provider business mailing address

10800 KEY WEST AVE
NORTHRIDGE CA
91326-2621
US

V. Phone/Fax

Practice location:
  • Phone: 213-217-5396
  • Fax:
Mailing address:
  • Phone: 818-219-2494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number10370
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: