Provider Demographics
NPI:1578156246
Name:ORTIZ, LETICIA GABRIELA (RD)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:GABRIELA
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 RUTHERFORD PL
Mailing Address - Street 2:
Mailing Address - City:NORTH ARLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07031-6303
Mailing Address - Country:US
Mailing Address - Phone:646-389-9196
Mailing Address - Fax:
Practice Address - Street 1:576 VALLEY BROOK AVE STE M1
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:NJ
Practice Address - Zip Code:07071-1919
Practice Address - Country:US
Practice Address - Phone:646-389-9196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-14
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ86197858133VN1006X, 133VN1201X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management