Basic Information
| Provider Information | |||||||||
| NPI: | 1457027674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVITT | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Credential: | MS, RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2595 SE 50TH AVE APT 227 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972061582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5157079112 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10180 SE SUNNYSIDE RD | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970158970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038132000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2021 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.