Provider Demographics
NPI:1033394911
Name:AVITIA, SANDRA (RD)
Entity Type:Individual
Prefix:MISS
First Name:SANDRA
Middle Name:
Last Name:AVITIA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 WESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-1860
Mailing Address - Country:US
Mailing Address - Phone:708-655-5061
Mailing Address - Fax:
Practice Address - Street 1:2111 WESLEY AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-1860
Practice Address - Country:US
Practice Address - Phone:708-655-5061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered