Provider Demographics
NPI:1508360918
Name:OTTALAGANA, ELENI
Entity Type:Individual
Prefix:
First Name:ELENI
Middle Name:
Last Name:OTTALAGANA
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 1:2028 E BEN WHITE BLVD # 240-5658
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-6966
Mailing Address - Country:US
Mailing Address - Phone:413-636-5658
Mailing Address - Fax:
Practice Address - Street 1:2028 E BEN WHITE BLVD # 240-5658
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-6966
Practice Address - Country:US
Practice Address - Phone:413-636-5658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84388133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered