Provider Demographics
NPI:1942743497
Name:TAYLOR, CONNIE (RD, CDE)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 COSTA DEL MAR RD
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-4303
Mailing Address - Country:US
Mailing Address - Phone:951-333-3252
Mailing Address - Fax:
Practice Address - Street 1:3401 ENGINEER LN
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-7200
Practice Address - Country:US
Practice Address - Phone:951-333-3252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA966063133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered