Provider Demographics
NPI:1316692288
Name:MONTALTO, JESSIE (RD, LDN)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:
Last Name:MONTALTO
Suffix:
Gender:M
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 LIONEL WAY STE 204
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-7809
Mailing Address - Country:US
Mailing Address - Phone:863-419-8815
Mailing Address - Fax:
Practice Address - Street 1:410 LIONEL WAY STE 204
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-7809
Practice Address - Country:US
Practice Address - Phone:863-419-8815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND9797133N00000X
FL86151896133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist