Provider Demographics
NPI:1336876945
Name:DAESELEER, SOPHIA BROOKE (RD)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:BROOKE
Last Name:DAESELEER
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:PO BOX 1283
Mailing Address - Street 2:
Mailing Address - City:KEKAHA
Mailing Address - State:HI
Mailing Address - Zip Code:96752-1283
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27300 IRIS AVE
Practice Address - Street 2:
Practice Address - City:MORENO
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:951-251-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86294851133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered