Provider Demographics
NPI:1467840595
Name:NUESTRO, GLORIA S
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:S
Last Name:NUESTRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12571 DESTINO ST
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-8304
Mailing Address - Country:US
Mailing Address - Phone:562-924-1333
Mailing Address - Fax:562-402-7550
Practice Address - Street 1:12571 DESTINO ST
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-8304
Practice Address - Country:US
Practice Address - Phone:562-924-1333
Practice Address - Fax:562-402-7550
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230495133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered