Provider Demographics
NPI:1790507812
Name:ELLIS, TESSA (RDN)
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10500 SEA PEARL CV UNIT 7
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-8742
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10500 SEA PEARL CV UNIT 7
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-8742
Practice Address - Country:US
Practice Address - Phone:626-862-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered