Provider Demographics
NPI:1104102193
Name:BURTON, SANDRA B (RD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:B
Last Name:BURTON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 E CAMPBELL AVE
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-2139
Mailing Address - Country:US
Mailing Address - Phone:408-370-7731
Mailing Address - Fax:408-370-7732
Practice Address - Street 1:621 E CAMPBELL AVE
Practice Address - Street 2:SUITE 6B
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-2139
Practice Address - Country:US
Practice Address - Phone:408-370-7731
Practice Address - Fax:408-370-7732
Is Sole Proprietor?:No
Enumeration Date:2011-10-23
Last Update Date:2011-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA923957133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered