Provider Demographics
NPI:1265631436
Name:REVILLA, ELIZABETH B (MS, RD, LD, CSP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:B
Last Name:REVILLA
Suffix:
Gender:F
Credentials:MS, RD, LD, CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1547 CLIFTON RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-4008
Mailing Address - Country:US
Mailing Address - Phone:404-785-1784
Mailing Address - Fax:404-727-4828
Practice Address - Street 1:1547 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-4008
Practice Address - Country:US
Practice Address - Phone:404-785-1784
Practice Address - Fax:404-727-4828
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002723133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric