Provider Demographics
NPI:1871995696
Name:WANG, TAMMY
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:WANG
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 1:1016 TREVECCA PL
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-1405
Mailing Address - Country:US
Mailing Address - Phone:909-399-0822
Mailing Address - Fax:909-399-5162
Practice Address - Street 1:250 W 1ST ST STE 112
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4740
Practice Address - Country:US
Practice Address - Phone:909-626-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA804542133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered