Provider Demographics
NPI:1538905112
Name:MASCORRO CARDONA, CARINA CICLLELY (RDN/LD)
Entity type:Individual
Prefix:
First Name:CARINA
Middle Name:CICLLELY
Last Name:MASCORRO CARDONA
Suffix:
Gender:F
Credentials:RDN/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76031-5825
Mailing Address - Country:US
Mailing Address - Phone:941-210-9988
Mailing Address - Fax:
Practice Address - Street 1:203 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76031-5825
Practice Address - Country:US
Practice Address - Phone:941-210-9881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT88286133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered