Provider Demographics
NPI:1659856706
Name:DEAVILLA, ELIZABETH (RDN, LDN)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:
Last Name:DEAVILLA
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6912 N LAKEWOOD AVE APT 1E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-3779
Mailing Address - Country:US
Mailing Address - Phone:847-477-6467
Mailing Address - Fax:
Practice Address - Street 1:6912 N. LAKEWOOD AVE
Practice Address - Street 2:APT 1E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-6062
Practice Address - Country:US
Practice Address - Phone:847-477-6467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.005357133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered