Provider Demographics
NPI:1073119160
Name:DIFUSCO, GINA (RD)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:DIFUSCO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-1415
Mailing Address - Country:US
Mailing Address - Phone:845-222-8587
Mailing Address - Fax:
Practice Address - Street 1:20 RIDGE LN
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-1415
Practice Address - Country:US
Practice Address - Phone:845-222-8587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-05
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
86150783133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered