Provider Demographics
NPI:1558838946
Name:BARRIS, MAKENNA (RDN)
Entity Type:Individual
Prefix:
First Name:MAKENNA
Middle Name:
Last Name:BARRIS
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 1:1511 E MAPLE AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3304
Mailing Address - Country:US
Mailing Address - Phone:415-812-3061
Mailing Address - Fax:
Practice Address - Street 1:1507 20TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-3472
Practice Address - Country:US
Practice Address - Phone:415-812-3061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86069732133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered