Provider Demographics
NPI:1376906594
Name:CREGUT, KELSEA JOHANNA (RD)
Entity Type:Individual
Prefix:
First Name:KELSEA
Middle Name:JOHANNA
Last Name:CREGUT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KELSEA
Other - Middle Name:
Other - Last Name:PALACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5709 CHERRY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5515
Mailing Address - Country:US
Mailing Address - Phone:805-444-5919
Mailing Address - Fax:
Practice Address - Street 1:400 MOBIL AVE STE D27
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-6338
Practice Address - Country:US
Practice Address - Phone:805-444-5919
Practice Address - Fax:805-830-1735
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1036705133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB280422OtherMEDICARE