Provider Demographics
NPI:1053527713
Name:LIDDICOAT, SANDRA (RD)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:LIDDICOAT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:SANDI
Other - Middle Name:
Other - Last Name:LIDDICOAT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:118 MILLS RD
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-4633
Mailing Address - Country:US
Mailing Address - Phone:925-586-3224
Mailing Address - Fax:
Practice Address - Street 1:1868 CLAYTON RD
Practice Address - Street 2:SUITE 123
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-2547
Practice Address - Country:US
Practice Address - Phone:925-586-3224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA888381133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered