Provider Demographics
NPI:1528445343
Name:PERICONE, ISABELLA
Entity type:Individual
Prefix:
First Name:ISABELLA
Middle Name:
Last Name:PERICONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 321086
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-0118
Mailing Address - Country:US
Mailing Address - Phone:408-680-0008
Mailing Address - Fax:408-370-9088
Practice Address - Street 1:105 N BASCOM AVE
Practice Address - Street 2:STE 202
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1811
Practice Address - Country:US
Practice Address - Phone:408-993-1500
Practice Address - Fax:408-993-1521
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86010521133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist