Provider Demographics
NPI:1548648488
Name:QUINTANILLA, LIZLETTE (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:
First Name:LIZLETTE
Middle Name:
Last Name:QUINTANILLA
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
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 2646
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78502-2646
Mailing Address - Country:US
Mailing Address - Phone:956-362-5650
Mailing Address - Fax:956-362-2574
Practice Address - Street 1:2821 MICHAELANGELO DR STE 102B
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-1411
Practice Address - Country:US
Practice Address - Phone:956-362-5650
Practice Address - Fax:956-362-2599
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86049766133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX352435701Medicaid
TX352435701Medicaid