Provider Demographics
NPI:1740936210
Name:BAUMGARDNER, ISABELA FORTES (FDN-P, CIYT, CYT)
Entity type:Individual
Prefix:
First Name:ISABELA
Middle Name:FORTES
Last Name:BAUMGARDNER
Suffix:
Gender:F
Credentials:FDN-P, CIYT, CYT
Other - Prefix:
Other - First Name:ISABELA
Other - Middle Name:
Other - Last Name:FORTES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FDN-P, CIYT, CYT
Mailing Address - Street 1:18 CORTE EL BRAZO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-7023
Mailing Address - Country:US
Mailing Address - Phone:949-547-9673
Mailing Address - Fax:949-481-5282
Practice Address - Street 1:18 CORTE EL BRAZO # 18
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-7023
Practice Address - Country:US
Practice Address - Phone:949-547-9673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225143908