MEDICARE: NIA NICOLE CARRILLO MS, RYT, RMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133NN1002X	Nutrition Education Nutritionist
2	133N00000X	Nutritionist

General Provider Information

NPI Number	:	1073088431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIA NICOLE CARRILLO MS, RYT, RMT

Provider Business Mailing Address
First Line	:	4114 SWIFT AVE APT 5
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-2249
Country	:	US
Telephone Number	:	170-224-4013
Fax Number	:

Provider Business Practice Location Address
First Line	:	4114 SWIFT AVE APT 5
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-2249
Country	:	US
Telephone Number	:	170-224-4013
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/11/2018
Last Update Date	:	10/11/2018

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