Provider Demographics
NPI:1083959407
Name:DAVIS, ROBERTA LEE (RD)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:LEE
Last Name:DAVIS
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 1:4041 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3247
Mailing Address - Country:US
Mailing Address - Phone:614-447-9495
Mailing Address - Fax:614-447-9163
Practice Address - Street 1:4041 N HIGH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3247
Practice Address - Country:US
Practice Address - Phone:614-447-9495
Practice Address - Fax:614-447-9163
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6923133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered