Basic Information
| Provider Information | |||||||||
| NPI: | 1447488572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVOLA | ||||||||
| FirstName: | JOSEFINE | ||||||||
| MiddleName: | LAMPASONA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAMPASONA | ||||||||
| OtherFirstName: | JOSEFINE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, RD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 22201 MOROSS | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138868787 | ||||||||
| FaxNumber: | 3138868084 | ||||||||
| Practice Location | |||||||||
| Address1: | 25710 KELLY RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480664959 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862915669 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2009 | ||||||||
| LastUpdateDate: | 09/03/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 947399 | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 947399 | MI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.