Provider Demographics
NPI:1376679167
Name:LACCETTI MONGIELLO, LORRAINE (RD, CDE, BC-ADM)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:LACCETTI MONGIELLO
Suffix:
Gender:F
Credentials:RD, CDE, BC-ADM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-1731
Mailing Address - Country:US
Mailing Address - Phone:631-724-1929
Mailing Address - Fax:631-474-6161
Practice Address - Street 1:200 BELLE TERRE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1928
Practice Address - Country:US
Practice Address - Phone:631-474-6430
Practice Address - Fax:631-474-6161
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9102E1Medicare ID - Type Unspecified
NYP85452Medicare UPIN