Provider Demographics
NPI:1699264069
Name:BACA, KELSEY LYNN (RD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYNN
Last Name:BACA
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 1:522 WHISPERING TRL
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-0803
Mailing Address - Country:US
Mailing Address - Phone:909-815-5109
Mailing Address - Fax:
Practice Address - Street 1:23719 MOULTON PKWY
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1913
Practice Address - Country:US
Practice Address - Phone:949-587-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86041467133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered