Provider Demographics
NPI:1356899371
Name:ADEVA, VICKY (RDN IBCLC)
Entity type:Individual
Prefix:
First Name:VICKY
Middle Name:
Last Name:ADEVA
Suffix:
Gender:F
Credentials:RDN IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5852 GAVIOTA AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90805-4304
Mailing Address - Country:US
Mailing Address - Phone:562-570-4465
Mailing Address - Fax:562-570-1754
Practice Address - Street 1:1043 ELM AVE STE 401
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3296
Practice Address - Country:US
Practice Address - Phone:562-570-4465
Practice Address - Fax:562-570-1754
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA825881133V00000X
CAL-13187174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN