Provider Demographics
NPI:1003941345
Name:FAICCO, ANN (RDCDN)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:
Last Name:FAICCO
Suffix:
Gender:F
Credentials:RDCDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 BRADLEY DR
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956
Mailing Address - Country:US
Mailing Address - Phone:845-634-1567
Mailing Address - Fax:201-634-5385
Practice Address - Street 1:223 NORTH VAN DIEN AVENUE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-2736
Practice Address - Country:US
Practice Address - Phone:201-634-5355
Practice Address - Fax:201-634-5385
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
720814133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P91472Medicare UPIN