=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497410153
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DESTINY WARREN RDN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2021
-----------------------------------------------------
Last Update Date | 10/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4605 LA TUNA CT
-----------------------------------------------------
City | CAMARILLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93012-4035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-312-5796
-----------------------------------------------------
Fax | 805-764-8601
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4605 LA TUNA CT
-----------------------------------------------------
City | CAMARILLO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93012-4035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-312-5796
-----------------------------------------------------
Fax | 805-764-8601
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133VN1501X
-----------------------------------------------------
Taxonomy Name | Sports Dietetics Nutrition Registered Dietitian
-----------------------------------------------------
License Number | 86017154
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 86017154
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 133VN1006X
-----------------------------------------------------
Taxonomy Name | Metabolic Nutrition Registered Dietitian
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 133VN1101X
-----------------------------------------------------
Taxonomy Name | Gerontological Nutrition Registered Dietitian
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 133VN1201X
-----------------------------------------------------
Taxonomy Name | Obesity and Weight Management Nutrition Registered Dietitian
-----------------------------------------------------
License Number | 86017154
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 133VN1301X
-----------------------------------------------------
Taxonomy Name | Oncology Nutrition Registered Dietitian
-----------------------------------------------------
License Number | 86017154
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 133VN1005X
-----------------------------------------------------
Taxonomy Name | Renal Nutrition Registered Dietitian
-----------------------------------------------------
License Number | 86017154
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------