Provider Demographics
NPI:1063061752
Name:VEGA, CHRISTINE LAILA (RD)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LAILA
Last Name:VEGA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 PICKETT DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-6648
Mailing Address - Country:US
Mailing Address - Phone:904-707-7449
Mailing Address - Fax:
Practice Address - Street 1:291 PICKETT DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-6648
Practice Address - Country:US
Practice Address - Phone:904-707-7449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL44399133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered