Provider Demographics
NPI:1619386596
Name:PROFESSIONAL NUTRITION CONSULTING, PLLC
Entity type:Organization
Organization Name:PROFESSIONAL NUTRITION CONSULTING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN NUTRITIONIST
Authorized Official - Prefix:
Authorized Official - First Name:ELISA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:717-682-7729
Mailing Address - Street 1:2886 N HERITAGE ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-1522
Mailing Address - Country:US
Mailing Address - Phone:717-682-7729
Mailing Address - Fax:
Practice Address - Street 1:2886 N HERITAGE ST
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85396-1522
Practice Address - Country:US
Practice Address - Phone:717-682-7729
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003417261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service