Provider Demographics
NPI:1447932512
Name:JOHN, RESHMA SUSAN
Entity type:Individual
Prefix:
First Name:RESHMA
Middle Name:SUSAN
Last Name:JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 HALF DOME DR
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-8146
Mailing Address - Country:US
Mailing Address - Phone:559-681-5426
Mailing Address - Fax:
Practice Address - Street 1:412 HALF DOME DR
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-8146
Practice Address - Country:US
Practice Address - Phone:559-681-5426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86040170133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered