Provider Demographics
NPI:1891540100
Name:JUSTICIA, RACHEL ANN (NUTRITION COACH)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANN
Last Name:JUSTICIA
Suffix:
Gender:F
Credentials:NUTRITION COACH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 NE 55TH AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-3180
Mailing Address - Country:US
Mailing Address - Phone:503-319-3410
Mailing Address - Fax:
Practice Address - Street 1:16 NE 55TH AVE UNIT A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3180
Practice Address - Country:US
Practice Address - Phone:503-319-3410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach