Provider Demographics
NPI:1154096626
Name:VALLEJO, ABBY (RD)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:
Last Name:VALLEJO
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 1:310 N WESTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54914-2801
Mailing Address - Country:US
Mailing Address - Phone:920-968-2367
Mailing Address - Fax:
Practice Address - Street 1:310 N WESTHILL BLVD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-2801
Practice Address - Country:US
Practice Address - Phone:920-968-2367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86173669133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered