Provider Demographics
NPI:1306593280
Name:WANG, WAN YI (RD)
Entity type:Individual
Prefix:
First Name:WAN
Middle Name:YI
Last Name:WANG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:YI
Other - Middle Name:WAN
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23781 VIA EL ROCIO
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-3533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3230 E IMPERIAL HWY STE 300
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-6751
Practice Address - Country:US
Practice Address - Phone:559-740-3967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86074218133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered