Provider Demographics
NPI:1063662377
Name:NIETO, BERENICE ALEJANDRINA (IBCLC)
Entity Type:Individual
Prefix:
First Name:BERENICE
Middle Name:ALEJANDRINA
Last Name:NIETO
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-2517
Mailing Address - Country:US
Mailing Address - Phone:510-506-1135
Mailing Address - Fax:510-667-3139
Practice Address - Street 1:1000 SAN LEANDRO BLVD
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-1598
Practice Address - Country:US
Practice Address - Phone:510-618-3735
Practice Address - Fax:510-667-3139
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CA105-22276174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No174400000XOther Service ProvidersSpecialist