Provider Demographics
NPI:1902290893
Name:DE LA ROSA, COURTNEY (MCN, RDN, LD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:DE LA ROSA
Suffix:
Gender:F
Credentials:MCN, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 MARKETPLACE DR
Mailing Address - Street 2:APT 413
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76711-2448
Mailing Address - Country:US
Mailing Address - Phone:903-806-6981
Mailing Address - Fax:
Practice Address - Street 1:2500 MARKETPLACE DR
Practice Address - Street 2:APT 413
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76711-2448
Practice Address - Country:US
Practice Address - Phone:903-806-6981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered