Healthcare Provider Details

I. General information

NPI: 1265631436
Provider Name (Legal Business Name): ELIZABETH B REVILLA MS, RD, LD, CSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1547 CLIFTON RD NE
ATLANTA GA
30322-4008
US

IV. Provider business mailing address

1547 CLIFTON RD NE
ATLANTA GA
30322-4008
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-1784
  • Fax: 404-727-4828
Mailing address:
  • Phone: 404-785-1784
  • Fax: 404-727-4828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberLD002723
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: