Healthcare Provider Details

I. General information

NPI: 1972756823
Provider Name (Legal Business Name): ROSALEA PETILLO HYLAND MS RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEA P HYLAND MS RD LD

II. Dates (important events)

Enumeration Date: 10/23/2008
Last Update Date: 10/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 WEST 12TH STREET 800 MARSHALL STREET SLOT 900
LITTLE ROCK AR
72202
US

IV. Provider business mailing address

14 BRENTWOOD CV
CABOT AR
72023-7301
US

V. Phone/Fax

Practice location:
  • Phone: 501-364-6577
  • Fax:
Mailing address:
  • Phone: 501-941-7645
  • Fax: 501-843-8504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number585
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: