Provider Demographics
NPI:1528284619
Name:HERMOGENO, ESTRELLITA ANDAL (RD)
Entity type:Individual
Prefix:
First Name:ESTRELLITA
Middle Name:ANDAL
Last Name:HERMOGENO
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 1:13698 BALBOA CT
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-3401
Mailing Address - Country:US
Mailing Address - Phone:909-899-7502
Mailing Address - Fax:
Practice Address - Street 1:765 W COLLEGE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-1181
Practice Address - Country:US
Practice Address - Phone:213-580-7299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA407875133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered