Healthcare Provider Details

I. General information

NPI: 1962038216
Provider Name (Legal Business Name): LILLIE LUU NGUYEN LDN, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 WEBSTER ST
SAN FRANCISCO CA
94115-1820
US

IV. Provider business mailing address

2460 39TH AVE
SAN FRANCISCO CA
94116-2153
US

V. Phone/Fax

Practice location:
  • Phone: 818-293-7367
  • Fax:
Mailing address:
  • Phone: 818-331-7271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX4748
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: