Basic Information
| Provider Information | |||||||||
| NPI: | 1184247736 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JULIEANNE | ||||||||
| MiddleName: | CYHANIUK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | REGISTERED DIETITIAN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CYHANIUK | ||||||||
| OtherFirstName: | JULIE | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10418 BOGARDUS AVE UNIT 2 | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906032600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097312558 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12462 PUTNAM ST STE 3030 | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906021048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626980811 | ||||||||
| FaxNumber: | 5627894335 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2020 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86079631 | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.