Provider Demographics
NPI:1457699837
Name:AVILA, JAIME (RD)
Entity type:Individual
Prefix:MS
First Name:JAIME
Middle Name:
Last Name:AVILA
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 1:3679 EXPEDITION DR
Mailing Address - Street 2:
Mailing Address - City:TRIANGLE
Mailing Address - State:VA
Mailing Address - Zip Code:22172-2071
Mailing Address - Country:US
Mailing Address - Phone:253-222-1592
Mailing Address - Fax:
Practice Address - Street 1:9300 DEWITT LOOP
Practice Address - Street 2:
Practice Address - City:FORT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5285
Practice Address - Country:US
Practice Address - Phone:712-313-3735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-20
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDI100000546133V00000X
MDDX3346133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered