Healthcare Provider Details

I. General information

NPI: 1265100747
Provider Name (Legal Business Name): AMY ANN MARIE ESPOSITO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 W 10TH ST APT 207
SAN PEDRO CA
90731-3401
US

IV. Provider business mailing address

1110 W 10TH ST APT 207
SAN PEDRO CA
90731-3401
US

V. Phone/Fax

Practice location:
  • Phone: 310-736-8755
  • Fax:
Mailing address:
  • Phone: 310-736-8755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1081744
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: