Provider Demographics
NPI:1366783839
Name:CHAN, VICKIE MAY (MS, RD)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:MAY
Last Name:CHAN
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 1:2652 GARDI ST
Mailing Address - Street 2:
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-1330
Mailing Address - Country:US
Mailing Address - Phone:626-757-8644
Mailing Address - Fax:
Practice Address - Street 1:2652 GARDI ST
Practice Address - Street 2:
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-1330
Practice Address - Country:US
Practice Address - Phone:626-757-8644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-08
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1058064133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered