Provider Demographics
NPI:1497442925
Name:GOMEZ, STEPHANIE (RDN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 B ST # 3093
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-2208
Mailing Address - Country:US
Mailing Address - Phone:909-241-6706
Mailing Address - Fax:
Practice Address - Street 1:15131 CRANE ST
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-0207
Practice Address - Country:US
Practice Address - Phone:909-241-6706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86154408133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered