Provider Demographics
NPI:1497345193
Name:LASTARZA, EMILY
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:LASTARZA
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 1:927 MONTE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-6051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:927 MONTE VISTA DR
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-6051
Practice Address - Country:US
Practice Address - Phone:610-241-0275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004217133VN1101X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1101XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Gerontological