Healthcare Provider Details

I. General information

NPI: 1295200061
Provider Name (Legal Business Name): SYDNEY BREE HANSEN MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 W GRANT LINE RD
TRACY CA
95377-7309
US

IV. Provider business mailing address

7210 MURRAY DRIVE P.O. BOX 779
STOCKTON CA
95201
US

V. Phone/Fax

Practice location:
  • Phone: 209-820-1500
  • Fax:
Mailing address:
  • Phone: 209-373-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86080492
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: