Provider Demographics
NPI:1376243964
Name:BORICK, ANJELICA MAE MADELYN (RDE)
Entity Type:Individual
Prefix:
First Name:ANJELICA
Middle Name:MAE MADELYN
Last Name:BORICK
Suffix:
Gender:F
Credentials:RDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2667 ENTERPRISE RD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89512-1666
Mailing Address - Country:US
Mailing Address - Phone:775-688-1341
Mailing Address - Fax:
Practice Address - Street 1:2667 ENTERPRISE RD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89512-1666
Practice Address - Country:US
Practice Address - Phone:775-688-1341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV40430-PDT-0133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered