Healthcare Provider Details

I. General information

NPI: 1194593426
Provider Name (Legal Business Name): AMBER SEXTON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMBER LOPEZ

II. Dates (important events)

Enumeration Date: 12/15/2023
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD # 120
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

11301 WILSHIRE BLVD # 120
LOS ANGELES CA
90073-1003
US

V. Phone/Fax

Practice location:
  • Phone: 310-478-3711
  • Fax:
Mailing address:
  • Phone: 310-478-3711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86294308
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: