Provider Demographics
NPI:1053316539
Name:KANSAL, KUSUM L (RD,CDE)
Entity Type:Individual
Prefix:MRS
First Name:KUSUM
Middle Name:L
Last Name:KANSAL
Suffix:
Gender:F
Credentials:RD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 AGAWAM DR
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2060
Mailing Address - Country:US
Mailing Address - Phone:973-460-7560
Mailing Address - Fax:973-696-3532
Practice Address - Street 1:332 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NJ
Practice Address - Zip Code:07506-2506
Practice Address - Country:US
Practice Address - Phone:973-460-7560
Practice Address - Fax:862-239-6059
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ586681133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ084640Medicare ID - Type Unspecified