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General NPI Number Information
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NPI Number | 1619126083
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Entity Type | Individual
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Provider Name | MEDORA LITTLE RD
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Gender | Female
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Dates
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Enumeration Date | 09/10/2008
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Last Update Date | 03/12/2010
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Provider Practice Location Address
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Address Line | 482 ND MEDICAL SQUADRON 12749 ELMENDORF ST, BLDG 347
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City | HOMESTEAD AFB
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State | FL
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Zip | 33039-0001
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Country | US
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Telephone | 304-224-7309
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Fax |
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Provider Business Mailing Address
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Address Line | 1472 21ST ST SW
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City | LARGO
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State | FL
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Zip | 33770-4743
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Country | US
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Telephone | 813-827-9360
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | ND 3219
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License Number State | FL
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