Provider Demographics
NPI:1679053680
Name:LIU, ELISE (MPH, RDN)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:LIU
Suffix:
Gender:F
Credentials:MPH, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11070 STRATHMORE DR APT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-2341
Mailing Address - Country:US
Mailing Address - Phone:415-887-8972
Mailing Address - Fax:
Practice Address - Street 1:11070 STRATHMORE DR APT 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-2341
Practice Address - Country:US
Practice Address - Phone:415-887-8972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-19
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86056939133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA86056939OtherCOMMISSION ON DIETETIC REGISTRATION