Healthcare Provider Details

I. General information

NPI: 1659771905
Provider Name (Legal Business Name): DELORES PUFAHL R.D.,L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2014
Last Update Date: 08/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7610 253RD ST E
MYAKKA CITY FL
34251-5883
US

IV. Provider business mailing address

7610 253RD ST E
MYAKKA CITY FL
34251-5883
US

V. Phone/Fax

Practice location:
  • Phone: 941-915-8057
  • Fax: 509-696-9631
Mailing address:
  • Phone: 941-915-8057
  • Fax: 509-696-9631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1716
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: