Healthcare Provider Details

I. General information

NPI: 1578505780
Provider Name (Legal Business Name): REVONDOLYN L SCOTT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8135 W LYNWOOD ST
PHOENIX AZ
85043
US

IV. Provider business mailing address

8135 W LYNWOOD ST
PHOENIX AZ
85043-1144
US

V. Phone/Fax

Practice location:
  • Phone: 602-330-2502
  • Fax:
Mailing address:
  • Phone: 602-330-2502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND4121
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number865489
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: