Provider Demographics
NPI:1275827008
Name:ALTAVILLA, NOELLE DOMINIQUE (RD, LDN)
Entity Type:Individual
Prefix:
First Name:NOELLE
Middle Name:DOMINIQUE
Last Name:ALTAVILLA
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 MACK BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:
Practice Address - Street 1:141 N VINE ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-5852
Practice Address - Country:US
Practice Address - Phone:570-501-6322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X, 133V00000X
PADN003742133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist