Provider Demographics
NPI:1164082079
Name:GUADAGNA, JENNA (RD, CDN)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:GUADAGNA
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MONTREPOSE AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-6526
Mailing Address - Country:US
Mailing Address - Phone:716-909-0360
Mailing Address - Fax:
Practice Address - Street 1:300 INTERNATIONAL DR STE 100
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5783
Practice Address - Country:US
Practice Address - Phone:716-710-7022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009254133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered