Provider Demographics
NPI:1871965665
Name:FAVELA, EDNA KARINA (RD, CDE)
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:KARINA
Last Name:FAVELA
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12168 MOUNT VERNON AVE UNIT 80
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5545
Mailing Address - Country:US
Mailing Address - Phone:909-638-3272
Mailing Address - Fax:
Practice Address - Street 1:12168 MOUNT VERNON AVE UNIT 80
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5545
Practice Address - Country:US
Practice Address - Phone:909-638-3272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1000367174H00000X
CA21420614174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator