Provider Demographics
NPI:1114644267
Name:BASSO, STEFANIE (CPT CNS, MS)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:
Last Name:BASSO
Suffix:
Gender:F
Credentials:CPT CNS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 PORTE DE MERANO UNIT 92
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-1935
Mailing Address - Country:US
Mailing Address - Phone:808-226-2113
Mailing Address - Fax:
Practice Address - Street 1:6612 MISSION GORGE RD STE B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-2346
Practice Address - Country:US
Practice Address - Phone:808-226-2113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2717254133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty