Provider Demographics
NPI:1164082053
Name:DE GUZMAN-WALTERS, MARY JOY INOCEDA (RD)
Entity Type:Individual
Prefix:MRS
First Name:MARY JOY
Middle Name:INOCEDA
Last Name:DE GUZMAN-WALTERS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MS
Other - First Name:MARY JOY
Other - Middle Name:INOCEDA
Other - Last Name:DE GUZMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPH, RD, LD
Mailing Address - Street 1:11768 VIA ESPERANZA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138
Mailing Address - Country:US
Mailing Address - Phone:702-493-1176
Mailing Address - Fax:
Practice Address - Street 1:11768 VIA ESPERANZA AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89138
Practice Address - Country:US
Practice Address - Phone:702-493-1176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV848585133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered