Provider Demographics
NPI:1851170013
Name:GAVIOLA, SISSELL (RDN)
Entity Type:Individual
Prefix:
First Name:SISSELL
Middle Name:
Last Name:GAVIOLA
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9124 90TH ST
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-3017
Mailing Address - Country:US
Mailing Address - Phone:347-922-1126
Mailing Address - Fax:
Practice Address - Street 1:9124 90TH ST
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-3017
Practice Address - Country:US
Practice Address - Phone:347-922-1126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86167791133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered