Provider Demographics
NPI:1437530193
Name:VILLALTA, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:VILLALTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 82969
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33682-2969
Mailing Address - Country:US
Mailing Address - Phone:813-866-0930
Mailing Address - Fax:813-405-3722
Practice Address - Street 1:302 W FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-3415
Practice Address - Country:US
Practice Address - Phone:813-397-5300
Practice Address - Fax:813-549-7855
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003299133V00000X
FLND10491133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered