Healthcare Provider Details

I. General information

NPI: 1104746924
Provider Name (Legal Business Name): AVERY ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 16TH ST APT 522
SAN FRANCISCO CA
94103-5139
US

IV. Provider business mailing address

1301 16TH ST APT 522
SAN FRANCISCO CA
94103-5139
US

V. Phone/Fax

Practice location:
  • Phone: 209-403-5712
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86377860
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: