Provider Demographics
NPI:1073088431
Name:CARRILLO, NIA NICOLE (MS, RYT, RMT)
Entity Type:Individual
Prefix:
First Name:NIA
Middle Name:NICOLE
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:MS, RYT, RMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4114 SWIFT AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2249
Mailing Address - Country:US
Mailing Address - Phone:170-224-4013
Mailing Address - Fax:
Practice Address - Street 1:4114 SWIFT AVE APT 5
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-2249
Practice Address - Country:US
Practice Address - Phone:170-224-4013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education