Provider Demographics
NPI:1831237734
Name:MCCORKLE, MONICA J (MS, RD, CDE)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:J
Last Name:MCCORKLE
Suffix:
Gender:F
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8065 DREXEL CT
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-4202
Mailing Address - Country:US
Mailing Address - Phone:619-463-6249
Mailing Address - Fax:
Practice Address - Street 1:2630 1ST AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-6599
Practice Address - Country:US
Practice Address - Phone:619-234-2158
Practice Address - Fax:619-234-2348
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA703180133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEQ606ZMedicare UPIN