Provider Demographics
NPI:1568944395
Name:VICTORIA, EVELYN LISSETTE (RDN, LDN, CNSC)
Entity Type:Individual
Prefix:MS
First Name:EVELYN
Middle Name:LISSETTE
Last Name:VICTORIA
Suffix:
Gender:F
Credentials:RDN, LDN, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 SW 143RD PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-3218
Mailing Address - Country:US
Mailing Address - Phone:786-606-4063
Mailing Address - Fax:
Practice Address - Street 1:1201 NW 16TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-1624
Practice Address - Country:US
Practice Address - Phone:305-575-3257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND6533133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered