Provider Demographics
NPI:1578505780
Name:SCOTT, REVONDOLYN L (RD)
Entity Type:Individual
Prefix:MS
First Name:REVONDOLYN
Middle Name:L
Last Name:SCOTT
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 1:8135 W LYNWOOD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-1144
Mailing Address - Country:US
Mailing Address - Phone:602-330-2502
Mailing Address - Fax:
Practice Address - Street 1:8135 W LYNWOOD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043
Practice Address - Country:US
Practice Address - Phone:602-330-2502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
FLND4121133V00000X
865489133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8293ZMedicare ID - Type Unspecified