Provider Demographics
NPI:1245686963
Name:BURKHOLDER-COOLEY, NASIRA (DRPH, RD)
Entity type:Individual
Prefix:DR
First Name:NASIRA
Middle Name:
Last Name:BURKHOLDER-COOLEY
Suffix:
Gender:F
Credentials:DRPH, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 S MILLIKEN AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-8102
Mailing Address - Country:US
Mailing Address - Phone:844-695-4331
Mailing Address - Fax:
Practice Address - Street 1:603 S MILLIKEN AVE
Practice Address - Street 2:SUITE F
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-8102
Practice Address - Country:US
Practice Address - Phone:844-695-4331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1077006133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered