Healthcare Provider Details

I. General information

NPI: 1750746707
Provider Name (Legal Business Name): ANDY MAYHEW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2015
Last Update Date: 12/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 HUMBOLDT ST #D
SANTA ROSA CA
95404-4287
US

IV. Provider business mailing address

431 HUMBOLDT ST #D
SANTA ROSA CA
95404-4287
US

V. Phone/Fax

Practice location:
  • Phone: 707-480-7419
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number142012
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: