MEDICARE: MS. REVONDOLYN L SCOTT RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist
2	133V00000X	Registered Dietitian	ND4121	FL
3	133N00000X	Nutritionist	865489

General Provider Information

NPI Number	:	1578505780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. REVONDOLYN L SCOTT RD

Provider Business Mailing Address
First Line	:	8135 W LYNWOOD ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85043-1144
Country	:	US
Telephone Number	:	602-330-2502
Fax Number	:

Provider Business Practice Location Address
First Line	:	8135 W LYNWOOD ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85043
Country	:	US
Telephone Number	:	602-330-2502
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	08/14/2018

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