Provider Demographics
NPI:1265174791
Name:PETTA, LENORE (RDN, LDN)
Entity type:Individual
Prefix:
First Name:LENORE
Middle Name:
Last Name:PETTA
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 1:7440 SAN CLEMENTE PL
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-1005
Mailing Address - Country:US
Mailing Address - Phone:786-763-0041
Mailing Address - Fax:
Practice Address - Street 1:7440 SAN CLEMENTE PL
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-1005
Practice Address - Country:US
Practice Address - Phone:786-763-0041
Practice Address - Fax:561-567-7756
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5866133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered