Provider Demographics
NPI:1730963992
Name:THAYER, IMOGENE AZALEA (RD)
Entity type:Individual
Prefix:MRS
First Name:IMOGENE
Middle Name:AZALEA
Last Name:THAYER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:IMOGENE
Other - Middle Name:AZALEA
Other - Last Name:CARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5625 OLD RANCH RD
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-5615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5625 OLD RANCH RD
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92057-5615
Practice Address - Country:US
Practice Address - Phone:707-672-9896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86173484133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered