Healthcare Provider Details

I. General information

NPI: 1073088431
Provider Name (Legal Business Name): NIA NICOLE CARRILLO MS, RYT, RMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4114 SWIFT AVE APT 5
SAN DIEGO CA
92104-2249
US

IV. Provider business mailing address

4114 SWIFT AVE APT 5
SAN DIEGO CA
92104-2249
US

V. Phone/Fax

Practice location:
  • Phone: 170-224-4013
  • Fax:
Mailing address:
  • Phone: 170-224-4013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: