Provider Demographics
NPI:1326136136
Name:MATZ-KHROMCHENKO, ILLANA (MS, RD)
Entity Type:Individual
Prefix:MRS
First Name:ILLANA
Middle Name:
Last Name:MATZ-KHROMCHENKO
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 1:11 HEDGEROW LN
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-7905
Mailing Address - Country:US
Mailing Address - Phone:718-646-8700
Mailing Address - Fax:718-646-8726
Practice Address - Street 1:3065 BRIGHTON 14TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5501
Practice Address - Country:US
Practice Address - Phone:718-646-8700
Practice Address - Fax:718-646-8726
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005384133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9364E1Medicare ID - Type Unspecified