Provider Demographics
NPI:1497516678
Name:DAVIS, HEATHER NICOLE (RDN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RDN
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 3280
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-3280
Mailing Address - Country:US
Mailing Address - Phone:505-506-7737
Mailing Address - Fax:
Practice Address - Street 1:3724 JEFFERSON ST STE 104
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6204
Practice Address - Country:US
Practice Address - Phone:505-506-7737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMLD-1227133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered