Healthcare Provider Details

I. General information

NPI: 1497410153
Provider Name (Legal Business Name): DESTINY WARREN RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2021
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 LA TUNA CT
CAMARILLO CA
93012-4035
US

IV. Provider business mailing address

4605 LA TUNA CT
CAMARILLO CA
93012-4035
US

V. Phone/Fax

Practice location:
  • Phone: 805-312-5796
  • Fax: 805-764-8601
Mailing address:
  • Phone: 805-312-5796
  • Fax: 805-764-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number86017154
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86017154
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1101X
TaxonomyGerontological Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number86017154
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License Number86017154
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number86017154
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: