Healthcare Provider Details

I. General information

NPI: 1225231236
Provider Name (Legal Business Name): EVA M VIVIAN REGISTERED DIETITIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 S PARK ST
MADISON WI
53713-1916
US

IV. Provider business mailing address

3434 E WASHINGTON AVE
MADISON WI
53704-4155
US

V. Phone/Fax

Practice location:
  • Phone: 608-443-5480
  • Fax: 608-443-5553
Mailing address:
  • Phone: 608-443-5480
  • Fax: 608-443-5553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number14843-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: