Provider Demographics
NPI:1033645528
Name:CAMPA PEREZ, NELLIE ELIZABETH (RD, CDE)
Entity Type:Individual
Prefix:
First Name:NELLIE
Middle Name:ELIZABETH
Last Name:CAMPA PEREZ
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11801 PIERCE ST
Mailing Address - Street 2:STE 200
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-4400
Mailing Address - Country:US
Mailing Address - Phone:951-317-7657
Mailing Address - Fax:
Practice Address - Street 1:724 SEQUOIA ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-2529
Practice Address - Country:US
Practice Address - Phone:909-559-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-03
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86038877133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered