Provider Demographics
NPI:1548003445
Name:DE GUZMAN, LEAH ANNE LOPEZ (RD)
Entity type:Individual
Prefix:
First Name:LEAH ANNE
Middle Name:LOPEZ
Last Name:DE GUZMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 DECOTO RD STE 100
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-3599
Mailing Address - Country:US
Mailing Address - Phone:209-915-6355
Mailing Address - Fax:
Practice Address - Street 1:1320 DECOTO RD STE 100
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-3599
Practice Address - Country:US
Practice Address - Phone:510-404-2511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86080408133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty