Basic Information
| Provider Information | |||||||||
| NPI: | 1710619275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUEVEDO | ||||||||
| FirstName: | PRISCILA | ||||||||
| MiddleName: | VERONICA | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2270 JOE BATTLE BLVD STE E-G | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799382609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9156429444 | ||||||||
| FaxNumber: | 9158008570 | ||||||||
| Practice Location | |||||||||
| Address1: | 2270 JOE BATTLE BLVD STE E-G | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799382609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9156429444 | ||||||||
| FaxNumber: | 9158008570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2022 | ||||||||
| LastUpdateDate: | 09/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DT94406 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | DT94406 | 01 | TX | TEXAS DEPARTMENT OF LICENSING AND REGULATION | OTHER | 86023099 | 01 | TX | COMMISION ON DIETETIC REGISTRATION | OTHER |