Provider Demographics
NPI:1194341354
Name:WONG, ROBIN M (RDN)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:M
Last Name:WONG
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:M
Other - Last Name:WITHROW-WONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDN
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95612-0369
Mailing Address - Country:US
Mailing Address - Phone:916-799-4639
Mailing Address - Fax:
Practice Address - Street 1:51200 PUMPHOUSE ROAD
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:CA
Practice Address - Zip Code:95612
Practice Address - Country:US
Practice Address - Phone:916-799-4639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86064294133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered