Provider Demographics
NPI:1578356333
Name:MANSOORI, NAKISA
Entity type:Individual
Prefix:
First Name:NAKISA
Middle Name:
Last Name:MANSOORI
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 1:824 LEGACY RD
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-8878
Mailing Address - Country:US
Mailing Address - Phone:678-656-9206
Mailing Address - Fax:
Practice Address - Street 1:824 LEGACY RD
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-8878
Practice Address - Country:US
Practice Address - Phone:678-656-9206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-26
Last Update Date:2025-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered