Provider Demographics
NPI:1780346528
Name:BALLESTA, DANIELLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:BALLESTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2477 STEAMBOAT SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-2248
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3350 LA JOLLA VILLAGE DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0002
Practice Address - Country:US
Practice Address - Phone:858-642-3752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86070857136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered