Provider Demographics
NPI:1821514092
Name:RAO, MAMTA
Entity Type:Individual
Prefix:
First Name:MAMTA
Middle Name:
Last Name:RAO
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 1:6630 CRESTMONT GLEN LN
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-6408
Mailing Address - Country:US
Mailing Address - Phone:407-325-9320
Mailing Address - Fax:
Practice Address - Street 1:633 UMATILLA BLVD
Practice Address - Street 2:
Practice Address - City:UMATILLA
Practice Address - State:FL
Practice Address - Zip Code:32784-8418
Practice Address - Country:US
Practice Address - Phone:352-771-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA864035133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered