Provider Demographics
NPI:1104214311
Name:BERRY, PATRICIA (RD,LD,CDE)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:BERRY
Suffix:
Gender:F
Credentials:RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12865 CAMINITO DEL CANTO
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-3758
Mailing Address - Country:US
Mailing Address - Phone:858-472-2184
Mailing Address - Fax:
Practice Address - Street 1:12526 HIGH BLUFF DR STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2067
Practice Address - Country:US
Practice Address - Phone:512-375-3210
Practice Address - Fax:858-205-1430
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-23
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT83283133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX387305ZG8JOtherMEDICARE ID