Provider Demographics
NPI:1124612486
Name:BLACK, NATALIE (RD/RDN)
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:RD/RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19847 SERRANO RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2605
Mailing Address - Country:US
Mailing Address - Phone:760-508-8439
Mailing Address - Fax:
Practice Address - Street 1:26600 CACTUS AVE FL 1
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3901
Practice Address - Country:US
Practice Address - Phone:951-486-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86038133133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered