Healthcare Provider Details

I. General information

NPI: 1619751237
Provider Name (Legal Business Name): JENNIFER L VARGAS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2023
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 1055
GROTTOES VA
24441-1055
US

IV. Provider business mailing address

1217 FLATT LN
GROTTOES VA
24441-2420
US

V. Phone/Fax

Practice location:
  • Phone: 401-480-6963
  • Fax:
Mailing address:
  • Phone: 401-480-6963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN006621
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND10169
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX3568
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI200001391
License Number StateDC
# 5
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164009400
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: