Provider Demographics
NPI:1255904512
Name:BERNARDO, MARA DA LUZ (RDN, CSO)
Entity type:Individual
Prefix:MRS
First Name:MARA
Middle Name:DA LUZ
Last Name:BERNARDO
Suffix:
Gender:F
Credentials:RDN, CSO
Other - Prefix:
Other - First Name:MARA
Other - Middle Name:DA LUZ
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, CSO
Mailing Address - Street 1:415 W BENJAMIN HOLT DR STE B3
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-3958
Mailing Address - Country:US
Mailing Address - Phone:209-227-0722
Mailing Address - Fax:866-862-8832
Practice Address - Street 1:415 W BENJAMIN HOLT DR STE B3
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-3958
Practice Address - Country:US
Practice Address - Phone:209-227-0722
Practice Address - Fax:866-862-8832
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86033078133V00000X, 133VN1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1301XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Oncology
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered