Provider Demographics
NPI:1275120883
Name:ROMAN, CERISSA (MPH, RDN)
Entity Type:Individual
Prefix:MRS
First Name:CERISSA
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:MPH, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1074 VIEJO HILLS DR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92610-3029
Mailing Address - Country:US
Mailing Address - Phone:863-558-5218
Mailing Address - Fax:
Practice Address - Street 1:1074 VIEJO HILLS DR
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92610-3029
Practice Address - Country:US
Practice Address - Phone:863-558-5218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA951354133VN1005X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal