Provider Demographics
NPI:1790300259
Name:BRANCH, DETRIA LATASHA (MS, RDN, RHNC)
Entity Type:Individual
Prefix:MS
First Name:DETRIA
Middle Name:LATASHA
Last Name:BRANCH
Suffix:
Gender:F
Credentials:MS, RDN, RHNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10208 BON AIRE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79924-2936
Mailing Address - Country:US
Mailing Address - Phone:505-417-0036
Mailing Address - Fax:915-301-9251
Practice Address - Street 1:10208 BON AIRE DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79924-2936
Practice Address - Country:US
Practice Address - Phone:888-474-4486
Practice Address - Fax:915-301-9251
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2023-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 133N00000X, 133NN1002X, 174H00000X, 261QG0250X, 261QH0100X
NMLD2023085133V00000X
TXDT88116133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No261QG0250XAmbulatory Health Care FacilitiesClinic/CenterGeneticsGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service