Provider Demographics
NPI:1275982837
Name:THIPPHAVONG, ALICE (MS, RD)
Entity type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:
Last Name:THIPPHAVONG
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 SABAL CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-2866
Mailing Address - Country:US
Mailing Address - Phone:408-729-1247
Mailing Address - Fax:
Practice Address - Street 1:1290 TULLY RD STE 60
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95122-3069
Practice Address - Country:US
Practice Address - Phone:408-275-0105
Practice Address - Fax:408-275-0115
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-05
Last Update Date:2016-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILR519736133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal