Provider Demographics
NPI:1962175505
Name:OPALKA, VICTORIA LEE (RD, CDN)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LEE
Last Name:OPALKA
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:473 LEPPER RD
Mailing Address - Street 2:
Mailing Address - City:FORT JOHNSON
Mailing Address - State:NY
Mailing Address - Zip Code:12070-1606
Mailing Address - Country:US
Mailing Address - Phone:518-774-2571
Mailing Address - Fax:
Practice Address - Street 1:99 E STATE ST
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-1293
Practice Address - Country:US
Practice Address - Phone:518-773-5414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010628133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered