Provider Demographics
NPI:1073056602
Name:LUCCHESI, CARLY (RDN)
Entity Type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:
Last Name:LUCCHESI
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18040 ROB RIC RD
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-8211
Mailing Address - Country:US
Mailing Address - Phone:209-396-7403
Mailing Address - Fax:844-413-7182
Practice Address - Street 1:18040 ROB RIC RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-8211
Practice Address - Country:US
Practice Address - Phone:209-396-7403
Practice Address - Fax:844-413-7182
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1027686133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered