Provider Demographics
NPI:1699139360
Name:MOGANNAM, CINDY (MPH, RD, CSP)
Entity type:Individual
Prefix:
First Name:CINDY
Middle Name:
Last Name:MOGANNAM
Suffix:
Gender:F
Credentials:MPH, RD, CSP
Other - Prefix:
Other - First Name:CINDY
Other - Middle Name:
Other - Last Name:DAGHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:101 BROOKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-5258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 BROOKWOOD AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5258
Practice Address - Country:US
Practice Address - Phone:707-575-6043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric