Provider Demographics
NPI:1194398156
Name:MITTLER, MARLO NANCI (MS RD)
Entity Type:Individual
Prefix:
First Name:MARLO
Middle Name:NANCI
Last Name:MITTLER
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4212
Mailing Address - Country:US
Mailing Address - Phone:516-857-6465
Mailing Address - Fax:
Practice Address - Street 1:173 E SHORE RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-2456
Practice Address - Country:US
Practice Address - Phone:516-857-6465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY819264133V00000X, 133VN1004X
IL819264133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered