Provider Demographics
NPI:1760144919
Name:VEZINA, MACY (RD, LD)
Entity Type:Individual
Prefix:
First Name:MACY
Middle Name:
Last Name:VEZINA
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5405 RUSTY ANCHOR CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-1547
Mailing Address - Country:US
Mailing Address - Phone:310-922-0270
Mailing Address - Fax:
Practice Address - Street 1:3365 E FLAMINGO RD STE 9
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-7440
Practice Address - Country:US
Practice Address - Phone:310-922-0270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV39611-DI-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered