Healthcare Provider Details

I. General information

NPI: 1649663600
Provider Name (Legal Business Name): ELIZABETH LOUISE AMELIA QUINTANA MS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6046 CORNERSTONE CT W SUITE 104
SAN DIEGO CA
92121-4758
US

IV. Provider business mailing address

836 W PENNSYLVANIA AVE APT 104
SAN DIEGO CA
92103-3849
US

V. Phone/Fax

Practice location:
  • Phone: 619-518-1928
  • Fax:
Mailing address:
  • Phone: 619-518-1928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number911569
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number911569
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number911569
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: