Provider Demographics
NPI:1841919107
Name:VENEGAS, TIFFANY NICOLE (RDN)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:VENEGAS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:NICOLE
Other - Last Name:QUINTERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:PO BOX 592
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92822-0592
Mailing Address - Country:US
Mailing Address - Phone:714-603-8424
Mailing Address - Fax:
Practice Address - Street 1:650 TAMARACK AVE APT 4411
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-3262
Practice Address - Country:US
Practice Address - Phone:714-603-8424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86057236133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered