=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881450245
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAWN RAE KIRSTEN DE LA VEGA RDHAP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2024
-----------------------------------------------------
Last Update Date | 02/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21823 BLUE HORIZON CT
-----------------------------------------------------
City | BIG OAK VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95977-9518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-798-3115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 557
-----------------------------------------------------
City | PENN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95946-0557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-798-3115
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number | HAP1052
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | HAP1052
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------