Healthcare Provider Details

I. General information

NPI: 1699019042
Provider Name (Legal Business Name): LAUREN REZENDE MPH, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2012
Last Update Date: 11/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4977 WOOD ST
LA MESA CA
91941-5475
US

IV. Provider business mailing address

4977 WOOD ST
LA MESA CA
91941-5475
US

V. Phone/Fax

Practice location:
  • Phone: 619-971-0384
  • Fax:
Mailing address:
  • Phone: 619-971-0384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number898906
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: