Provider Demographics
NPI:1275286353
Name:TINEO, CRYSTAL (RD, CDN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:TINEO
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 1:51 KENSINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-2331
Mailing Address - Country:US
Mailing Address - Phone:347-255-6275
Mailing Address - Fax:
Practice Address - Street 1:51 KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-2331
Practice Address - Country:US
Practice Address - Phone:347-255-6275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-30
Last Update Date:2022-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008159-1133N00000X
NY1055317133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist