Provider Demographics
NPI:1619682572
Name:MITNICK, JUDITH GAIL
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:GAIL
Last Name:MITNICK
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 1:4632 LODGEPOLE DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-4700
Mailing Address - Country:US
Mailing Address - Phone:757-679-9712
Mailing Address - Fax:
Practice Address - Street 1:848 FIRST COLONIAL RD STE B
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-6126
Practice Address - Country:US
Practice Address - Phone:757-422-4728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered