Provider Demographics
NPI:1083795231
Name:VELA, MAGNOLIA
Entity Type:Individual
Prefix:
First Name:MAGNOLIA
Middle Name:
Last Name:VELA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6285 E SPRING ST # 284
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-4020
Mailing Address - Country:US
Mailing Address - Phone:562-424-4055
Mailing Address - Fax:949-577-4880
Practice Address - Street 1:6285 E SPRING ST # 284
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-4020
Practice Address - Country:US
Practice Address - Phone:562-424-4055
Practice Address - Fax:949-577-4880
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMNT894684133VN1005X, 133VN1006X, 133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMNT894684OtherREG DIETICIAN PROVIDER NO
CAMNT894684Medicare ID - Type Unspecified