Provider Demographics
NPI:1699251066
Name:PROVENCIO, CAITLIN (RD)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
Last Name:PROVENCIO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 E GREENLEE PL
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-1816
Mailing Address - Country:US
Mailing Address - Phone:520-425-0712
Mailing Address - Fax:
Practice Address - Street 1:5300 E ERICKSON DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2828
Practice Address - Country:US
Practice Address - Phone:520-324-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered