Healthcare Provider Details

I. General information

NPI: 1851122980
Provider Name (Legal Business Name): EMILY HETZEL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2024
Last Update Date: 08/10/2024
Certification Date: 08/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 786
TAHOMA CA
96142-0786
US

IV. Provider business mailing address

PO BOX 786
TAHOMA CA
96142-0786
US

V. Phone/Fax

Practice location:
  • Phone: 530-386-3614
  • Fax:
Mailing address:
  • Phone: 530-386-3614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86084383
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: