Provider Demographics
NPI:1093079246
Name:BRONHEIM, ILANA BETH (MS, RD, CDN)
Entity Type:Individual
Prefix:
First Name:ILANA
Middle Name:BETH
Last Name:BRONHEIM
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1621 EASTCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2604
Mailing Address - Country:US
Mailing Address - Phone:718-405-8352
Mailing Address - Fax:
Practice Address - Street 1:1621 EASTCHESTER RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2604
Practice Address - Country:US
Practice Address - Phone:718-405-8352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-02
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1027329133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered