Provider Demographics
NPI:1679191423
Name:SANTANA CASTILLO, PAMELA
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:SANTANA CASTILLO
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 1:1100 INDUSTRIAL BLVD SPC C37
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-2679
Mailing Address - Country:US
Mailing Address - Phone:619-227-5156
Mailing Address - Fax:
Practice Address - Street 1:1809 NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-2113
Practice Address - Country:US
Practice Address - Phone:619-515-2526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education