Provider Demographics
NPI:1417309170
Name:DAVILA, MARY LORETTA (RD IBCLC)
Entity Type:Individual
Prefix:
First Name:MARY LORETTA
Middle Name:
Last Name:DAVILA
Suffix:
Gender:F
Credentials:RD IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 MIDDLEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-3404
Mailing Address - Country:US
Mailing Address - Phone:650-578-7141
Mailing Address - Fax:650-298-6881
Practice Address - Street 1:2710 MIDDLEFIELD RD
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-3404
Practice Address - Country:US
Practice Address - Phone:650-578-7141
Practice Address - Fax:650-298-6881
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA853097133V00000X
L-19656174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN