Provider Demographics
NPI:1346365087
Name:AVITABILE, MICHELE (MS, RD, CDN)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:AVITABILE
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 1:133 CONNECTICUT ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10307-1519
Mailing Address - Country:US
Mailing Address - Phone:917-574-9398
Mailing Address - Fax:
Practice Address - Street 1:65 CROMWELL AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-3944
Practice Address - Country:US
Practice Address - Phone:718-667-8100
Practice Address - Fax:718-667-6280
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY850647133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY850647OtherCOMM ON DIETETIC REGIS.