Provider Demographics
NPI:1801506886
Name:MONTOYA, GENNIFER M (Z58464)
Entity type:Individual
Prefix:MRS
First Name:GENNIFER
Middle Name:M
Last Name:MONTOYA
Suffix:
Gender:F
Credentials:Z58464
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 AVENIDA DEL MAR STE F
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-4007
Mailing Address - Country:US
Mailing Address - Phone:949-636-8145
Mailing Address - Fax:
Practice Address - Street 1:215 AVENIDA DEL MAR STE F
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4007
Practice Address - Country:US
Practice Address - Phone:949-636-8145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist