Provider Demographics
NPI:1376673996
Name:SACCONE, ROBERTA H (RD)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:H
Last Name:SACCONE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2908 KINGS CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-2409
Mailing Address - Country:US
Mailing Address - Phone:812-331-1320
Mailing Address - Fax:
Practice Address - Street 1:600 N JORDAN AVENUE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47405-3191
Practice Address - Country:US
Practice Address - Phone:812-855-7338
Practice Address - Fax:812-855-4628
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001747A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered