Provider Demographics
NPI:1386693042
Name:DEMEZZO, SANDRA (RD, LD)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:
Last Name:DEMEZZO
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 LIELMANIS AVE
Mailing Address - Street 2:16 MDOS/SGOAZ
Mailing Address - City:HURLBURT FIELD
Mailing Address - State:FL
Mailing Address - Zip Code:32544-5613
Mailing Address - Country:US
Mailing Address - Phone:850-622-2010
Mailing Address - Fax:850-884-6321
Practice Address - Street 1:452 CODY AVE
Practice Address - Street 2:SUITE 127 A
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544-5417
Practice Address - Country:US
Practice Address - Phone:850-884-4292
Practice Address - Fax:850-884-6321
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 1859133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered