Provider Demographics
NPI:1285799452
Name:VEGA, CARISSA (NUTRITIONIST)
Entity type:Individual
Prefix:MRS
First Name:CARISSA
Middle Name:
Last Name:VEGA
Suffix:
Gender:F
Credentials:NUTRITIONIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NW 84TH AVE STE 200A
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-1817
Mailing Address - Country:US
Mailing Address - Phone:954-577-3249
Mailing Address - Fax:954-424-0765
Practice Address - Street 1:350 NW 84TH AVE STE 200A
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-1817
Practice Address - Country:US
Practice Address - Phone:954-577-3249
Practice Address - Fax:954-424-0765
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND3403133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLN0142Medicare ID - Type Unspecified