Provider Demographics
NPI:1073875688
Name:VICINAIZ, ILEANA (RD, LD)
Entity Type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:VICINAIZ
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:PALMHURST
Mailing Address - State:TX
Mailing Address - Zip Code:78573-8353
Mailing Address - Country:US
Mailing Address - Phone:956-519-7509
Mailing Address - Fax:
Practice Address - Street 1:2305 COUNTRY LN
Practice Address - Street 2:
Practice Address - City:PALMHURST
Practice Address - State:TX
Practice Address - Zip Code:78573-8353
Practice Address - Country:US
Practice Address - Phone:956-519-7509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-10
Last Update Date:2012-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT02610133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered