Provider Demographics
NPI:1609294552
Name:PEREZ-VERGARA, JOANNE (RDN LD/N)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:
Last Name:PEREZ-VERGARA
Suffix:
Gender:F
Credentials:RDN LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2799 TURTLE SHORES DR
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-6645
Mailing Address - Country:US
Mailing Address - Phone:912-443-4200
Mailing Address - Fax:912-644-5260
Practice Address - Street 1:2799 TURTLE SHORES DR
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-6645
Practice Address - Country:US
Practice Address - Phone:864-436-7324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLLDN8288133V00000X
GALD004223133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered