Basic Information
| Provider Information | |||||||||
| NPI: | 1083856835 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WORMALD | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | JACQUELYN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12401 WASHINGTON BLVD | ||||||||
| Address2: | CLINCIAL NUTRITION SERVICES | ||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906021006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626980811 | ||||||||
| FaxNumber: | 5624896409 | ||||||||
| Practice Location | |||||||||
| Address1: | 12401 WASHINGTON BLVD | ||||||||
| Address2: | CLINCIAL NUTRITION SERVICES | ||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906021006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626980811 | ||||||||
| FaxNumber: | 5624896409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2009 | ||||||||
| LastUpdateDate: | 03/25/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 883876 | CA | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133VN1004X | 883876 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric |
No ID Information.