Provider Demographics
NPI:1104230648
Name:MORENO-BRYCE, KARLA (MDA RD LD)
Entity type:Individual
Prefix:
First Name:KARLA
Middle Name:
Last Name:MORENO-BRYCE
Suffix:
Gender:F
Credentials:MDA RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3248 XENIA AVE N
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2638
Mailing Address - Country:US
Mailing Address - Phone:805-469-5252
Mailing Address - Fax:
Practice Address - Street 1:3248 XENIA AVE N
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55422-2638
Practice Address - Country:US
Practice Address - Phone:805-469-5252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-12
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3899133V00000X, 133VN1004X
CA86002577133N00000X, 133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric