Basic Information
| Provider Information | |||||||||
| NPI: | 1124648050 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PREZIOSO | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS, RDN, CLE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 27305 LIVE OAK RD UNIT A89 | ||||||||
| Address2: | |||||||||
| City: | CASTAIC | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913844520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183999115 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13803 FOOTHILL BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SYLMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913423013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188981388 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2020 | ||||||||
| LastUpdateDate: | 04/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1004X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric | 133VN1201X | N | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.