Provider Demographics
NPI:1073109013
Name:VANDENBURGH, KOURTNEY (RD)
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:
Last Name:VANDENBURGH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CHINQUAPIN AVE APT C16
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-3528
Mailing Address - Country:US
Mailing Address - Phone:760-505-0506
Mailing Address - Fax:
Practice Address - Street 1:100 E SAN MARCOS BLVD STE 400
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2988
Practice Address - Country:US
Practice Address - Phone:760-563-7045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1106546133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered