Provider Demographics
NPI:1427177047
Name:DAVILA - ORTIZ, IVELISSE (LND)
Entity type:Individual
Prefix:MRS
First Name:IVELISSE
Middle Name:
Last Name:DAVILA - ORTIZ
Suffix:
Gender:F
Credentials:LND
Other - Prefix:MRS
Other - First Name:IVELISSE
Other - Middle Name:
Other - Last Name:DAVILA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LND
Mailing Address - Street 1:448 CALLE ALVA
Mailing Address - Street 2:CIUDAD REAL
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693-3652
Mailing Address - Country:US
Mailing Address - Phone:787-642-2240
Mailing Address - Fax:
Practice Address - Street 1:448 CALLE ALVA
Practice Address - Street 2:CIUDAD REAL
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-3652
Practice Address - Country:US
Practice Address - Phone:787-642-2240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1165133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education